EXTERNAL  DISEASES  OF  THE  EYE 


ATLAS 


OF 


External  Diseases  of  the  Eye 


Physicians  and  Students 


BY 


Dr.  Richard  Greeff 

PROFESSOR    OF   OPHTHALMOLOGY   IN   THE   UNIVERSITY  OF 
BERLIN   AND    CHIEF   OF  THE    ROYAL    OPHTHAL- 
MIC CLINIC   IN  THE   CHARITE   HOSPITAL 


ONLY  AUTHORIZED   ENGLISH  TRANSLATION 

BY 

P.  W.  Shedd.  M.D. 

NEW  YORK 

WITH   84   ILLUSTRATIONS    IN    COLOR   FROM   WAX    MODELS    PRINTED    ON    64. 

PLATCS  WITH    EXPLANATORY  TEXT.     THE   ILLUSTRATIONS 

ARE   FROM    MODELS   IN  THE   PATHOPLASTIC 

INSTITUTE    IN    BERLIN 

ART  Director:    f.  kolbow 


NEW  YORK 

rebman  company 

1  123    BROADWAY 


vv  w  q 


CopywGHT,  1909 
By  Rebman  Company,  New  York 


All  rights  reserved 


MAIL    AND   tXPRESe   JOB    PRINT,    B-IB   MUHRAV  6T   .    NBW  VOPK 


DEDICATED 

TO 

MY  DEAR   COLLEAGUE 
DR.   THEODOR  AXENFELD 

Professor  of  Ophthalmology  and  Chief 

of  the  Ophthalmic  Clinic  in  the 

University  of  Freiburg 

In  Remembrance  of  true  and  unbroken 

friendship  since  the  days  of 

student  life 


Preface. 

Foe  years,  in  conjunction  with  the  sculptor,  F.  Koi- 
bow,  I  have  endeavored  to  perpetuate  in  wax  models 
the  appearance  of  important  external  diseases  of  the 
eye.  Because  of  the  delicacy  and  sensitivity  of  oph- 
thalmic tissues,  the  difficulties  to  overcome  were,  nat- 
urally, very  great,  and  only  after  much  experiment 
were  we  able  to  discover  the  correct  method. 

The  request  of  the  publishers,  Urban  &  Schwarz- 
enberg,  to  prepare  an  Atlas  of  the  most  important 
external  diseases  of  the  eye  was  acceded  to  only  when 
I  was  convinced  that  modern  art  could  produce  pic- 
tures of  distinctly  better  technic  than  those  hitherto 
published. 

The  plates  were  obtained  by  making,  after  a  special 
method,  a  mask  of  the  living  subject,  which  was  then 
filled  with  wax.  From  the  wax  models  photographic 
reproduction  in  four  colors  was  made. 

We  thus  gain  two  advantages,  viz.,  we  have  before 
us,  not  a  schematic  representation,  but  the  actual  case 
as  it  appeared  in  the  University  Ophthalmic  Clinic  of 
the  Berlin  Charite  Hospital  of  which  I  am  chief,  and, 
so  to  speak,  no  man's  hand  has  touched  it.  Further- 
more, by  means  of  the  models,  we  get  a  pictorial  plas- 
ticity unattainable  by  the  most  accomplished  draughts- 
man. 

Although  the  work  appears  under  my  name,  I  am 
fully  conscious  that  only  a  portion  thereof  is  actually 
mine. 

To  the  skill,  powers  of  observation  and  zealous  par- 


ticipation  of  Sculptor  Kolbow  (Berlin),  success  in 
obtaining  the  beautiful  plates  is  largely  due.  He  is, 
probably,  surpassed  by  no  one  to-day  in  the  fabrica- 
tion of  wax  models. 

A  number  of  the  false  eyes  inserted  into  the  models 
simulate  the  pathologic  aspect  of  the  organ,  and  were 
prepared  in  accordance  with  my  specifications  by  the 
optical  firm  of  Miiller  Bros.  (Wiesbaden)  and  by  Hans 
Huning  (Berlin). 

The  drawings  were  made  by  the  expert  scientific 
draughtsman,  H.  Helbig. 

The  execution  of  the  plates  in  color  was  undertaken 
by  the  firm  of  Dr.  Selle  &  Co.  The  difficulties  here 
were  so  great  that  at  first  many  of  the  plates  were 
necessarily  rejected.  Finally,  I  may  mention  with 
commendation  the  willingness  of  the  firm  to  make  all 
alterations  and  corrections,  and  that,  too,  with  no 
diminution  of  its  productive  ability. 

The  printing  of  the  plates  was  most  carefully  and 
satisfactorily  accomplished  by  the  firm  of  Doring  & 
Huning  (Berlin). 

Figs.  4  and  5  were  taken  from  Bockenheimer's  Atlas 
of  Surgical  Diseases,  and  Fig.  8  from  the  Atlas  of 
Skin  Diseases  by  Jacobi,  both  of  which  works  are  pub- 
lished by  the  same  house. 

Last,  but  not  least,  an  expression  of  my  gratitude 
and  content  is  due  the  publishers.  Urban  &  Schwarz- 
enberg,  who,  notwithstanding  the  enormous  expense 
of  the  undertaking,  have  invariably  sought  to  conjoin 
in  the  work  the  best  offered  by  modern  science  and 
technic,  neglecting  no  method  or  experiment  necessary 
to  such  accomplishment. 

We  hope  for  a  substantiation  of  our  aim  in  prepar- 
ing this  volume. 

Pbof.  R.  Gbeeff. 

Berlin,  February,  1909. 

VIU. 


rcclf.  Alias. 


Fig.    1. 
Erysipelas  Faciei  —  Oedema  palpebrarum 


?L-biii.Tii  Company,  New  York 


Erysipelas  Faciei,  Oedema 
Palpebrarum. 

Plate  I.,  Fig.  1. 

Facial  erysipelas,  also  called  St.  Anthony's  fire 
(German:  Gesichtsrose,  Rotlauf),  follows,  commonly, 
some  slight  injury  of  the  skin  (vesicle,  bleb,  eczema, 
excoriations,  rhagades),  which  serves  as  a  point  of 
entry  for  the  streptococcus  erysipelatis.  With  high 
fever,  sometimes  with  chills,  there  develops  a  sharply- 
contoured,  glistening  red  swelling  of  the  skin,  which 
extends  rapidly,  and  at  last,  usually  involves  the  entire 
face.  Within  a  short  time  the  epiderm  is  raised  up  in 
few  or  many  blebs. 

The  eyelids  present  a  markedly  reddened  skin ;  upon 
their  margins  the  blebs  are  particularly  apt  to  develop 
(Fig.  1,  right  eye) ;  and  there  is  great  timief action,  so 
that,  as  a  rule,  the  eyes  cannot  be  opened.  The  ex- 
treme inflammatory  palpebral  edema  is  due  to  the  loose 
connection  here  betwixt  the  skin  and  the  underlying 
tissues,  to  the  absence  of  subcutaneous  fat,  and  to  the 
fact  that  there  is  present  abundant  space  for  the  ex- 
tension of  a  tumef active  process  (C/.  infra:  Edema). 

Commonly,  the  temperature  gradually  falls  after  a 
few  days ;  the  blebs  or  vesicles  break,  and,  with  retro- 
gression of  the  redness  and  swelling,  there  begin  ex- 
foliation and  pigmentation  of  the  affected  areas. 

The  diag'nosis  is  easily  made.  The  simultaneous 
appearance  of  fever  with  rubescent  and  glistening  skin 
renders  error  difficult. 

1 


The  progri^osis  is,  in  general,  good,  but  should 
be  carefully  guarded  in  expression.  When  there  is 
high  fever  and  exhaustion,  indicative  of  a  general  in- 
fection, death  may  follow.  In  very  serious  cases  pal- 
pebral gangrene  may  develop  as  an  unpleasant  com- 
plication (vide,  p.  11). 

It  is  to  be  remembered  that  in  convalescent  cases 
sudden  relapses  are  not  infrequent.  The  disease  con- 
fers no  immunity;  on  the  contrary,  one  attack  predis- 
poses to  another. 

Therapy  is  local  in  character  and  consists  in 
the  application  of  unguents  which  render  the  tense 
skin  more  supple  and  also  have  an  excellent  subjective 
effect.  Neutral  unguents  (boracic  acid,  resorcin,  etc.) 
are  best.  Others  prefer  cold  applications  (wet  cloths). 
Where  there  is  menacing  tension  of  the  lids  and  ex- 
treme pain,  scarification  of  the  skin  may  be  considered 
as  a  last  resort  (vide  Gangrene,  p.  11). 

General  treatment,  i.  e.,  rest  in  bed,  fever-diet,  etc., 
needs  no  discussion. 

Erysipelas  is  extremely  infectious,  and  requires, 
therefore,  the  most  perfect  isolation  possible. 

Edema  of  tlie  eyelids  is  not,  commonly,  a 
nosologic  entity. 

As  we  have  already  remarked,  the  derm  of  the  lid  is 
not  intimately  bound  to  the  subjacent  tissues,  so  that 
fluid  exudates  find  abundant  space  beneath  the  palpe- 
bral skin  and,  therefore,  are  often  apt  to  extend  to  a 
considerable  distance.  This  is  best  seen  in  palpebral 
hemorrhage  {vide  Fig.  2). 

Inflammatory  edemas  may  often  arise  from  slight 
irritations  (e.  g.,  bee-stings,  fly-bites)  and  spread  un- 
til the  lids  appear  like  bags  distended  with  water,  the 
eye   being   completely   occluded.     Palpebral   edemas, 

2 


then,  are  mostly  secondary  phenomena,  and  are  also 
noted  in  cases  of  abscess,  chalazion,  hordeolum,  dacro- 
cystitis,  orbital  phlegmon,  panophthalmia,  etc. 

Furthermore,  it  is  well-known  that  anasarca,  with 
simultaneous  swelling  of  the  ankle,  is  also  apt  to  de- 
velop palpebral  edema  (renal  disease). 

A  doughy  edema  of  the  lids  is  found  in  trichinosis, 
the  trichina?  having  a  predilection  for  the  orbital 
muscle. 


Haemorrhagia  Subdermalis  et 
Subconjunctivalis 

Plate  U.,  Fig.  2. 

Palpebral  sugillation  or  suffusion,  i.  e.,  haemorrhagia 
subdermalis,  is  a  very  striking  phenomenon.  Because 
of  the  spongy  tissue  beneath  the  skin,  the  blood  ex- 
tends easily  and  far.  The  red  tint  soon  changes  to  a 
reddish-blue  and  then  becomes  blue-black  (the  well- 
known  black  eye  resulting  from  a  blow).  The  hem- 
orrhage is,  commonly,  sharply  limited  at  the  orbital 
margin,  for  here  the  skin  is  firmly  attached  to  the 
bone  by  tense  connective  tissue.  The  skin  about  the 
root  of  the  nose  is,  on  the  contrary,  loosely  bound  to 
the  subjacent  tissue.  Hence,  the  hemorrhage  beneath 
the  sMn  of  one  eye  may  extend  under  the  skin  of  the 
nasal  bridge  and  appear,  with  correspondent  colora- 
tion, beneath  the  sMn  of  the  uninjured  optic.  It  fre- 
quently happens  that,  after  operation  on  one  eye,  hem- 
orrhagic discoloration  develops  in  both.  In  such  cases 
one  should  not  be  misled  to  the  conclusion  that  both 
eyes  had  suffered  injury. 

Sugillation  of  the  lids  is  particularly  a  sequela  of 
trauma,  notably  that  due  to  blows  with  blunt  objects 
(fist,  club,  etc.);  also  of  major  operations,  such  as 
enucleation,  where  the  wound  is  deep,  whilst  in  cuts  of 
palpebral  tissue  it  is  rarely  observed,  for  the  blood 
has  abundant  exit. 

Spontaneous  bleeding  may  also  occur,  for  the  vas- 
cular channels,  from  lack  of  supporting  tissue,  are 

4 


Fig.  2. 
Haemorrhagia  subdermalis  et  subconjunctivalis. 


?ebman  Company,  New  York. 


easily  ruptured,  as  during  violent  exertion,  by  crush- 
ing, sneezing,  coughing,  etc. 

Palpebral  sugillation  is  of  special  significance  in 
diagnosing  fracture  of  the  base  of  the  skull.  In  this 
grave  injury  the  blood  often  travels  from  the  seat  of 
fracture  forwards  along  the  floor  of  the  orbit,  appear- 
ing, usually  after  some  lapse  of  time,  beneath  the  con- 
junctiva {vide  infra)  and  the  skin  of  the  lower  lid, 
particularly  in  the  region  of  the  inner  canthus. 

The  discolored  skin  permits  instant  diagnosis,  and 
only  the  cause  of  the  hemorrhage  demands  further 
investigation. 

The  prognosis  is  commonly  favorable.  The  dis- 
coloration gradually  takes  on  a  greenish  hue,  and  in 
most  cases  the  blood  is  resorbed  after  a  few  weeks. 
Rarely,  the  effusion  passes  into  suppuration,  thus 
forming  a  palpebral  abscess. 

Therapy.    Cool  applications. 

Subconjunctival  hemorrhage  develops  even  more 
easily,  for  here,  likewise,  there  is  very  loose  attach- 
ment to  underlying  tissues,  and  we  have:  haemor- 
rhagia  suhconjunctivalis,  hyphaema  conjunctivae  or, 
briefly,  hyposphagma. 

In  youth  it  almost  invariably  accompanies  pertussis 
and  may  also  be  caused  by  immoderate  coughing, 
pressure  or  strangling  in  children.  In  older  individ- 
uals it  is  indicative  of  vascular  fragility,  of  arterio- 
sclerosis, and  often  accompanies  contracted  kidney. 

Conjunctival  hemorrhages  have,  therefore,  weighty 
symptomatic  significance. 

The  diagnosis  is  not  difficult :  the  uniform,  super- 
ficial reddening,  if  once  seen,  will  not  be  confused  with 
an  inflammation  of  the  conjunctiva,  where  the  indi- 
vidual dilated  blood-vessels  are  easily  distinguished. 

5 


Local  therapy  is  of  little  value.  The  striking 
phenomenon  of  a  subconjunctival  hemorrhage  usually 
terrifies  the  patient  or  those  about  him,  but  they  may 
Be  easily  calmed,  for  the  eye  is  never  damaged.  How- 
ever, lead-water  or  cold  compresses  should  be  applied. 
The  constitutional  cause  of  the  hemorrhage  is  to  be 
sought  and  treated.  The  phenomenon  is  frequently  a 
prodrome  of  cerebral  apoplexy. 


cff,  Atlas. 


Tab.  Ill 


Fig.  3. 

Morbilli.      Blepharo-Conjunctivitis  exanthematica. 


LibiiKiii  Company.  New  York. 


Morbilli— Conjunctivitis 
Exanthematica. 

Plate  III.,  Fig.  3. 

With  the  efflorescence  of  the  exanthem  in  the  various 
acute  general  infections,  but  notably  so  in  measles, 
characteristic  catarrhal  phenomena  commonly  appear 
in  the  form  of  more  or  less  violent  conjunctivitis  and 
blepharitis  with  redness,  photophobia,  and  secretion, 
as  well  as  catarrhal  conditions  in  the  nose  and  upper 
air-passages.  These  catarrhal  conditions  may  even 
precede  the  exanthematous  efflorescence  by  some  days, 
the  secretion  consisting  either  of  increased  lacrimal 
fluid  or,  not  rarely,  of  a  mucous  or  purulent  exudate 
drying  into  scales  and  crusts  along  the  margin  of  the 
lid  {vide  Fig.  3).  Croupous  membranes  seldom  de- 
velop. 

Prog'nosis.  In  measles  the  acute  conjunctival 
catarrh  always  present  is  not  to  be  slighted  Though 
spontaneously  disappearing,  in  most  cases,  after  2-3 
weeks,  it  may,  if  neglected,  lead  to  a  redness  and  sen- 
sitivity of  the  blepharo-conjunctival  tissues,  annoying 
the  patient  for  years  or  during  his  entire  life.  Serious 
comi^lications  such  as  a  blennorrhoic  or  diphtheritic 
conjunctivitis  or  corneal  infiltration  or  a  secondary 
iritis  are  not  impossible. 

Tlierapy.  As  with  measles  in  general,  cleanli- 
ness plays  a  chief  role  in  the  ophthalmic  treatment. 
The  lids  are  to  be  bathed  carefully  with  lukewarm 

7 


boracic  water  and  the  dried  exudate  softened  and  re- 
moved. In  most  eases,  this  will  suffice.  Where  lacri- 
mation  is  more  abundant,  one  drop  of  a  slightly  as- 
tringent collyrium  (acid,  tannicum  i%,  resorcin  i%, 
zinc  sulfate  Vifo)  may  be  used  daily.  With  purulent 
secretion  or  the  formation  of  membrane,  irrigation 
with  a  Vio  or  V*^"  solution  of  silver  nitrate  is  indicated. 
Where  such  conditions  develop,  the  globe  should  be 
closely  watched  for  pericorneal  injection  (atropin)  or 
corneal  infiltration. 

The  room  is  to  be  kept  moderately  darkened  and 
the  child  not  exposed  to  ordinary  light  until  all  oph- 
thalmic irritation  has  subsided. 


irccff,  Atl;is. 


Tab.  IV. 


Fig.  4. 
I'ustula  maligna  —  Anthrax. 


nan  Coinpaiiy,  New  York. 


Pustula  Maligna— Anthrax. 

Plate  IV.,  Fig.  4. 

The  anthrax  pustule  or  pustula  maligna  not  infre- 
quently appears  upon  the  eyelid.  Man  is  inoculated 
with  the  bacillus  anthracis  from  diseased  animals  by 
wiping,  rubbing  or  scratching  the  eyes  with  the  hand, 
and  malignant  pustule  is  therefore  found  in  individ- 
uals handling  animal  products  —  cattle  dealers, 
butchers,  tanners,  dealers  in  leather  or  furs.  The 
affection  often  begins  with  a  vesicle  on  the  margin  of 
the  lid  filled  with  yellow  turbid  or  bloody  matter. 
There  is  also  a  violent  inflammatory  edema  of  the  lid 
and  tense  infiltration  of  the  skin.  Soon  swelling  of  the 
preauricular  and  submaxillary  glands  and  fever  de- 
velop, followed  by  rupture  of  the  pustule  which  be- 
comes covered  by  a  scab.  The  surroimding  skin  then 
turns  a  grayish  color,  indicative  of  commencing  ne- 
crosis. 

Diag'nosis.  Similar  vesicular  formation  may 
also  be  found  in  phlegmonous  inflammations,  carbun- 
cle, and  in  glanders.  Bacteriologic  discovery  of  the 
specific  bacilli  (non-mobile  rods  with  square-cut  ends, 
often  in  long  chains)  renders  the  diagnosis  certain. 

The  prog'nosis  is  extremely  bad,  for  the  lids 
usually  become  necrosed,  and  the  case  terminates  in 
death. 

Formerly,  the  tlierapy  was  surgical:  incision, 
currettage,  or  a  Paquelin  cauterization.  We  have 
learned,  however,  that  the  less  the  site  of  infection  is 

9 


disturbed,  the  less  danger  there  is  of  bacterial  en- 
trance into  the  blood  stream.  Bearing  this  in  mind, 
the  best  treatment  is  the  application  of  unguents  or 
aseptic  compresses.  The  scabs  and  necrotic  tissues 
are  left  for  gradual  and  spontaneous  desquamation. 
If  the  infection  do  not  terminate  fatally,  plastic  sur- 
gery is  indicated. 

Fig.  4  shows  a  malignant  pustule  of  the  lid,  whose 
reproduction  in  this  atlas  was  kindly  permitted  by 
Prof.  Dr.  Bockenheimer.  The  case  is  one  of  external 
anthrax  infection  in  a  laborer  employed  in  a  tannery, 
and  developed  from  a  slight  scratch  in  the  skin  of  the 
cheek.  At  first,  a  red  nodule  appeared,  then  several 
vesicles  filled  with  a  yellow  Quid  of  bacillary  content. 
There  was  widespread  carbunculoid  infiltration, 
marked  edema  of  the  lids  and  an  erysipelatoid  redden- 
ing of  the  entire  cheek.  Soon  after  rupture  of  the 
vesicle  a  scab  formed  at  the  site  of  infection,  with  an 
areola  of  grayish  skin  gradually  passing  into  necro- 
sis. The  process,  with  marked  systemic  involvement, 
fever,  chills,  delirium,  then  extended  to  the  eyelids, 
which,  because  of  the  enormous  tumefaction,  could  no 
longer  be  opened  even  by  force.  Pustule  after  pustule 
developed,  with  correspondent  gangrene  of  the  skin 
after  their  rupture.  The  entire  half  of  the  face  was 
protected  by  an  unguental  application. 


10 


ff,  Atlas. 


lab.  V. 


Fig.  5. 
Gangraena  palpebrarum—  Anthrax. 


1  Company.   New  York  . 


Gangraena  Palpebrarum. 
Anthrax. 

Plate  V.,  Fia.  5. 

The  delicate  texture  of  the  palpebral  skin,  its  thin 
corium,  the  loose  subcutaneous  tissues  with  their  large 
lymph  spaces  and  the  richness  of  the  vascular  supply, 
permit  easy  extension  of  a  malignant  inflammation 
and  trophic  disturbance  of  tissue.  We  are  speaking 
of  gangrene  when  the  breaking-down  of  tissue  ele- 
ments occurs  with  decomposition  and  putrefaction. 
In  such  case,  we  find  in  the  palpebral  region  a  circum- 
scribed, fetid  necrosis  surrounded  by  a  zone  of  in- 
flammatory reaction. 

According  to  Romer,  to  whom  we  are  indebted  for  a 
study  of  the  subject,  gangrene  may  develop  endo- 
geously,  i.  e.,  by  metastasis,  or  ectogenously,  i.  e., 
from  some  local  disturbance. 

I.  The  Endogenous  Form.  Metastatic  gangrene  of 
the  lids  develops,  but  not  often,  in  severe  general  dis- 
eases, particularly  typhoid,  measles,  scarlatina.  Even 
in  1794,  Himly  reported  that  in  grave  typhoid  the  eye- 
lids became  blue  and  sphacelated  within  a  few  hours. 
Fieuzal  gives  three  cases  of  palpebral  gangrene  dur- 
ing measles,  and  similar  cases  are  recorded  by  Knies 
and  Eandall. 

Partial  gangrene  of  the  eyelid  in  scarlatina  is  de- 
scribed by  St.  Martin  and  Jackson,  whilst  numerous 
palpebral  abscesses  have  been  observed  in  influenza. 

In  pyemia  and  sepsis,  gangrene  of  the  lid  is  caused 

11 


by  infectious  emboli,  and  it  has  also  been  attributed  to 
diabetes  and  alcoholism. 

II.  The  Ectogenous  Form.  Here  the  necrosis  may 
proceed  from  foci  of  inflammation  in  the  neighborhood 
of  the  eye,  or  develop  primarily  in  the  palpebral  tissue. 

Secondary  necroses  of  the  lid  are  observed  most 
frequently  as  complications  of  facial  erysipelas.  The 
minutest  infected  wound  often  plays  a  role  here,  and 
more  extensive  injuries  are  not  rarely  etiologic. 
Schmidt-Eimpler  reports  a  case  where,  after  a  blow 
from  a  twig  upon  the  malar  bone,  timiefaction  of  the 
eyelid  developed,  and  five  days  later  the  palpebral  tis- 
sue was  transformed  into  an  ulcer  full  of  necrotic 
shreds. 

Among  the  primary  affections  of  the  lid  where  gan- 
grene is  possible,  anthrax  is  pre-eminent.  In  Gross- 
mann's  case,  we  are,  doubtless,  dealing  with  pustula 
maligna.  In  a  broom-maker  a  pustule  as  large  as  a 
pea  developed,  with  high  fever,  on  the  skin  of  the 
upi^er  eyelid,  whence  a  brawny  edema  spread,  reach- 
ing even  to  the  thorax.  By  the  third  day  the  skin  of 
the  entire  lid  had  become  transformed  into  a  black 
crust.    Cure  followed,  but  with  extreme  ectropion. 

For  therapy  consult  page  9. 

In  Fig.  5,  we  have  the  case  of  Prof.  Bockenheimer 
some  weeks  after  the  infection.  The  extensive  dermal 
gangrene,  cognizable  by  the  black  discoloration  and 
leathern  consistency,  is  already  delimited  by  a  zone 
of  pus  and  iinctuous  granulation  tissue  from  the  ad- 
jacent non-gangrenous  skin  which,  however,  is  slightly 
reddened  and  gives  evidence  of  inflammatory  infiltra- 
tion. But  the  necrosis  is  still  firmly  attached  to  the 
subjacent  tissue.  Its  forcible  removal  by  the  knife  or 
a  clumsy  extirpation  would  result  only  in  renascence 
of  the  infection.     Gradual  desquamation  was,  there- 

12 


fore,  attained  by  compresses  wet  with  hydrogen  per- 
oxid  and  boric  acid  solution  and  by  applications  of 
ointments.  In  this  ease,  after  the  loosening  of  ne- 
crotic tissues  and  subsidence  of  inflammatory  pro- 
cesses in  the  circumjacent  skin,  the  somewhat  marked 
defect  caused  by  the  loss  of  the  entire  upper  lid  was 
plastically  corrected  by  a  pediculated  flap  of  skin  from 
the  surrounding  healthy  tissue.  Despite  the  unfavor- 
able prognosis  in  facial  anthrax  and  the  severity  of 
the  local  process,  the  case  was  cured. 


13 


Herpes  Facialis. 

Plate  VI.,  Fig.  6;  Plate  VII.,  Figs.  7-8. 

Herpes  zo.ster  is  an  exanthematous  disease  of  tlie 
skin,  simulating  an  infection.  In  the  territory  sup- 
plied by  some  particulate  nerve  a  vesicular  eruption 
occurs  with  febrile  phenomena  and  general  weakness. 
The  number  of  vesicles  is  extremely  variable  in  differ- 
ent cases.  Sirring  and  autumn  are  the  seasons  of  elec- 
tion. 

The  vesicle  contains  at  first  a  clear  watery  fluid 
which  soon  becomes  turbid  and  purulent.  It  then  rup- 
tures and  the  resulting  ulcus  crusts  over. 

After  the  ulcers  heal,  permanent  scars  remain,  and 
as  a  rule,  the  individual  is  thenceforth  immune. 

Of  the  cranial  nerves  the  trigeminus  in  all  its 
branches  is  most  often  affected  and  we  have  a  herpes 
zoster  ophthalmicus,  usually  along  the  course  of  the 
first  branch  of  the  nerve.  In  such  case  the  vesicles 
are  found  on  the  upper  lid,  the  forehead  to  the  hairy 
margin  of  the  scalp,  and  on  the  nose,  although,  be- 
cause of  the  almost  invariable  onesidedness  of  the 
affection,  they  are  plainly  delimited  by  the  median  line 
of  the  face  (vide  Plate  VII.,  Fig.  7).  In  Fig.  8,  Plate 
VIII.,  there  are  uncompionly  numerous,  ruptured 
vesicles  covered  with  crusts  which  penetrate  deeply 
into  the  corium.  This  latter  case  is  borrowed  from 
Jacobi's  Atlas  of  Skin  Diseases. 

If  the  2nd  branch  of  the  trigeminus  is  affected,  the 
vesicles  are  located  upon  the  lower  lid  in  the  superior 
maxillary  or  malar  region  (Fig.  6,  Plate  VI). 

14 


ff.  Alias 


Tal).  VI. 


Fig.  6. 
Herpes  facialis 


nan  Company,  New  York. 


Qrceff.  Athis, 


TO 
6/3 


O 
N 


a 
X 


TO 

en 

O 

N 


Rebman  Conipanv,  New  York 


Not  infrequently  the  skin  disease  is  accompanied  by 
an  eruption  of  vesicles  on  the  cornea,  a  grave  compli- 
cation. 

Herpes  zoster  ophthalmicus  is  due  to  an  inflamma- 
tory involvement  of  the  trigeminus,  either  of  the 
Gasserian  ganglion,  of  the  ciliary  ganglion  or  of  the 
nerve  in  its  peripheral  course. 

Diag'nosis  of  herpes  zoster  ophthalmicus  is  easy 
because  of  the  distribution  of  the  vesicles  within  a  cer- 
tain neural  territory,  the  one-sidedness,  and  the  syn- 
chronous febrile  development.  It  is  differentiated 
from  simple  herpes  febrilis  (labialis)  by  the  size  of 
the  vesicles.  In  simple  herpes  the  epiderm  only  is 
vesiculated  whilst  in  herpes  zoster  the  ulcer  sinks 
deep  into  the  substance  of  the  corium  and  a  cicatrix 
remains  after  recovery. 

Prog-nosis  is  positively  favorable.  The  scars  left 
may  later  cause  some  annoyance. 

Therapy.  Internally,  salicyl  preparations  are 
called  for;  for  neuralgic  pains,  quinine,  antipyrin  or 
phenacetin.  The  affected  areas  are  best  powdered 
with  rice-starch,  lycopodium,  etc.,  which  dry  up  the 
vesicles.  When  crusted  over,  the  ulcerated  surface 
heals. 


15 


Variola  Vaccina. 

Plate  VIII.,  Figs.  9-10. 

Vaccinal  ophthalmia  develops  from  infection  of  the 
eye  with  the  lymph,  generally  by  direct  transmission 
by  the  finger  from  the  vaccination  into  the  optic;  but 
also  from  dried  lymph  on  bandages  or  the  handker- 
chief. 

On  the  eyelids  the  eruption  is  usually  found  along 
the  intermarginal  portions.  From  small,  superficial 
vesicles  there  develop,  with  marked  inflammatory 
symptoms,  chemosis,  palpebral  edema,  and  large,  flat 
ulcers  of  a  diphtheritic  appearance.  After  8  to  12 
days  healing  begins  with  complete  restitutio  ad  inte- 
grum in  2  to  3  weeks. 

The  extreme  brevity  of  the  incubation  stadium  may 
in  many  cases  be  reduced  to  3  to  4  days. 

The  variola  may  also  be  localized  upon  the  con- 
junctiva or  the  cornea. 

The  diagnosis  of  vaccinal  infection  of  the  eye 
can  offer  little  real  difficulty,  if  we  consider  the  mor- 
bidity (Schirmer).  Differentiation  from  variola  vera, 
where  the  pustules  cover  the  entire  surface  of  the 
body  and  grave  constitutional  symptoms  are  present, 
is  easy. 

The  ulcus  durum  (chancre)  does  not,  as  a  rule, 
cause  such  marked  inflammatory  phenomena  in  the  re- 
gion affected. 

Confusion  with  diphtheritic  conditions  is  possible, 
but  in  the  rarer  diphtheritic  ulceration  on  the  margin 

16 


reeff.  Atlas. 


Tab.  Vlll. 


Fig.  9.     Variola  vaccina 


Fig.   10.     Variola  vaccina 


;ebnian  Company,  New  York 


of  the  lid,  the  whitish  membrane  covering  the  conjunc- 
tiva is  seldom  lacking;  furthermore,  in  the  vaccinal 
ulceration  removal  of  the  membrane  leaves  a  clear 
red  base  whilst  in  diphtheria  the  base  of  the  ulceration 
is  dirty. 

Tlierapy.  Treatment  should  be  as  unobtrusive 
as  possible :  the  eye  should  be  kept  clean  and  the  ulcer 
covered  with  some  unguent.  Cauterizing  applications 
are  dangerous. 

Keratitis  profunda  or  an  ulcus  cornefe  will  develop 
severe  complications,  and  treatment  should  be  that 
adapted  to  these  affections. 

Prophylactically,  the  family  should  be  warned  that 
the  vaccinal  virus  may  be  transmitted  to  the  eye  by 
rubbing,  etc. 


17 


Ulcus  Durum. 

Plate  IX.,  Pig.  11. 

The  margin  of  the  eyelid  is  not  rarely  the  seat  of 
primary  infection,  usually  due  to  kissing  or  to  trans- 
mission by  the  finger.  The  indurations  seldom  de- 
velop on  the  outer  sMn  but  are  almost  invariably 
intermarginal  or  in  the  canthi  or  upon  the  conjunctiva 
tarsi.  The  reason  therefor  is  plain.  The  cutis  of  the 
lid  is  not  especially  permeable,  but  the  delicate  tex- 
tures of  the  canthi  where  denn  changes  to  mucosa, 
where  the  glands  of  the  ciliary  follicles  and  the  Mei- 
bomian glands  exude  their  contents  offer  facile  inoc- 
ulation of  the  virus.  The  pre-auricular  and  other 
glands  are  often  so  swollen  that  a  diagnosis  of  mumps 
might  be  possible. 

The  affection  begins  with  a  swelling  at  whose  apex 
a  slight  excoriation  increasing  in  depth  develops,  so 
that  finally  an  ulcer  (rarely  deep)  with  well-defined, 
indurated  margins  is  present. 

Diagnosis  of  the  extragenital  sclerosis  in  the 
early  stadia  is  extremely  difficult,  yet  error  would  be 
fateful  where  the  lesion  is  facial,  particularly  if  on 
the  eye  or  the  organs  protecting  it,  because  of  later 
possible  diminution  in  function.  In  differentiation 
from  similar  morbid  sjTidromes :  hordeolum,  cha- 
lazion, vaccine  pustule,  lupus,  tuberculosis,  diphtheria, 
chancroid  and  giunma,  the  most  dependable  pathog- 
nomic indication  is  the  frequently  marked,  but  indo 
lent,  swelling  of  neighboring  glands,  in  particulate,  the 

18 


ceff,  Atlas 


Tab.  IX 


Fig.    11. 
Ulcus  durum  palpebrae.     Syphilite.      Primary  affection. 


?ebrnan  Company,  New  York. 


pre-auricular  glands.  Not  rarely,  however,  only  the 
appearance  of  secondary  phenomena  and  the  result  of 
mercurial  treatment  permit  a  decision. 

Kowalewski  was  the  first  to  render  a  diagnosis  by 
demonstrating  the  spirochaeta  pallida  in  a  palpebral 
ulcer. 

Therapy  consists  in  local  cleanliness  by  irriga- 
tion with  weak  antiseptic  solutions  followed  by  the 
application  of  some  indifferent  salve.  Dusting  with 
iodoform  may  greatly  augment  the  inflammation  with- 
out other  benefit.  The  diagnosis  once  certain,  there 
is  no  reason  for  delaying  the  constitutional  treatment. 


19 


Xanthelasma. 

Plate  X.,  Fig.  12. 

Xanthelasma  is  a  flat,  straw-  or  sulfur-colored  tu- 
mor located  in  the  palpebral  skin,  and  generally  mul- 
tiple in  both  upper  and  lower  lid  in  the  region  of  the 
inner  canthus.  Often  a  tendency  is  noted  to  develop 
symmetric  figures  on  the  two  eyes.  These  tumors  are 
found  only  in  elderly  adults  and  more  often  in  women 
past  the  menopause.  They  grow  very  slowly  and  in- 
jure only  cosmetically.  When  extirpated  they  rarely 
return. 

Dermatologists  differentiate  a  X.  planum  and  a  X. 
tuberosima,  the  first  of  which  is  found  only  upon  the 
Uds. 

Anatomically  they  are  composed  of  the  so-called 
xanthoma-cells  (Touton),  i.  e.  hypertrophied  connec- 
tive tissue  cells,  lying  in  nests  and  filled  with  fat-drop- 
lets. These  nests  are  separated  from  one  another  by 
walls  of  connective  tissue.  Giant-cells  are  not  infre- 
quently found  in  them. 

Therapy  is  entirely  cosmetic  and  consists  of 
easily  executed  removal. 

Prognosis.  The  tumors  are  absolutely  benign, 
causing  only  disfiguration. 


20 


[.  Atliis 


Tab.  X. 


Fig.    12. 
Xanthelasma. 


Company,   New  York  . 


Atlns. 


I'lib.  XI, 


o 

.     CO 

""  o 
■   o 

ill  £ 


>1 


111  Company,   New  Vork . 


Atheromatous  Cyst  of  the 
Margin  of  the  Eyelid. 

Plate  XI.,  Fig.  13. 

By  atheroma  (Griitzbeutel)  is  meant  a  retention- 
cyst,  developing  from  sebaceous  glands  and  hair  fol- 
licles, and  containing  a  gritty,  whitish  mass  of  comi- 
fied,  degenerate  epithelial  cells,  fat-droplets  and 
cholesterin.  The  cyst  walls  are  thin,  as  a  rule,  and 
composed  of  connective  tissue. 

Atheromata  develop  usually  in  middle  age  on  the 
hairy  scalp  or  the  genitalia.  Not  infrequently  they 
are  found  on  the  margin  of  the  eyelid,  sometimes  mul- 
tiple, and  originating  in  the  ciliary  hair  follicles 
(glands  of  Zeiss).  The  cysts  arising  from  occluded 
sebaceous  glands  of  the  palpebral  margin,  the  so- 
called  glands  of  Moll,  develop  only  as  small  translu- 
cent blebs  the  size  of  a  pea  or  cherry. 

Diag'nosis  is  easily  established  from  the  loca- 
tion, painlessness  and  form  and  is  rendered  certain 
by  the  contents  of  the  cyst.  In  the  same  location  there 
may  also  be  found  congenital  dermoid  tumors  lying 
beneath  the  skin  of  the  lid,  usually  in  the  upper  lid 
in  either  canthus.  These  push  into  the  orbit  but,  as  a 
rule,  so  superficially  that  the  globe  is  not  displaced. 
Beneath  the  skin  they  may  be  palpated  as  easily  mov- 
able tumors  the  size  of  a  bean. 

Therapy  is  surgical,  but  the  extirpation  must  be 
thorough,  for  otherwise  they  are  apt  to  develop  again. 


21 


Molluscum  Contagiosum. 

Plate  XI.,  Fig.  14. 

Molluscum  contagiosum  (Cf.  Epithelioma)  is  a 
growth  composed  of  elevations,  generally  hempseed  in 
size,  rarely  as  large  as  peas,  yellowish-white  in  color 
and  occasionally  of  the  hue  of  mother-of-pearl,  cen- 
trally depressed.  From  this  depression  or  crater,  a 
gritty  matter  may  be  squeezed.  These  growths  occur 
anywhere  on  the  skin  but  are  most  conmion  on  the 
genitals  and  the  eyelids,  and  close  observation  will  de- 
tect them  in  the  latter  location  oftener  than  is  sup- 
posed— usually  multiple  on  the  lid  margins. 

The  tumor  is  contagious  and  hence,  in  persons  of 
uncleanly  habits,  apt  to  take  on  multiple  form.  If 
such  a  growth  exist  on  the  margin  of  the  upper  lid,  it 
is  not  long  before  one  develops  on  the  lower  lid  at  the 
point  of  contact.  A  blind  individual  whom  I  saw  had 
many  hundred  moUusca. 

Retzius  was  the  first  to  demonstrate  their  conta- 
giousness by  successful  inoculation. 

The  contents  expressed  from  the  nodule  contain, 
histologically,  cornified  epithelia  and  numerous  oval, 
very  refractive,  sharply  defined  bodies,  the  so-called 
molluscum  corpuscles, — easily  seen  in  sections  of  the 
extirpated  tmnor.  Virchow,  Caspary  and  Lasser  con- 
sider them  bladder-like  formations  due  to  an  altera- 
tion of  cell-protoplasm.  According  to  Bollinger,  they 
are  unicellular  parasites,  gregarinae,  whilst  Neisser 
considers  them  epithelial  cells  filled  with  gregarinae. 
Croker  takes  them  to  be  similar  to  the  oviform  cocci- 

22 


dimn  described  by  Leukhardt.  Recently  the  growth 
has  been  carefully  studied  by  Muetze  under  the  direc- 
tion of  Uhthoff  and  Axenfeld  and,  according  to  him, 
all  of  the  transitions  from  normal  epithelia  to  the  mol- 
luscal  corpuscles  are  observable.  The  latter,  then, 
are  to  be  considered  as  degenerate  epithelial  cells  and 
not  as  protozoic.  What  the  contagium  is,  we  do  not 
know. 

The  dlag-nosis  is  easily  gained  from  the  form  of 
the  tumor  with  the  central  depression  or  crater,  from 
which  a  core  may  be  expressed  in  which,  microscop- 
ically, the  molluscal  corpuscles  are  demonstrable. 

Therapy.  Expression  of  the  contents  seldom 
suffices.    It  is  best  to  remove  the  nodules  with  scissors. 


23 


Hordeolum. 

Plate  XH.,  Fig.  15. 

Hordeolum  or  sty  (Gerstenkorn)  is  the  name  given 
a  small  inflammatory  swelling  on  the  free  outer  mar- 
gin of  the  lid,  due  to  suppuration  of  sebaceous  glands 
and  is  merely,  in  other  parts  of  the  body,  the  derma- 
tologic  acne  vulgaris,  simplex  or  pustulacea.  The  se- 
baceous glands  of  the  free  palpebral  margin  corre- 
spond to  the  hair  follicles  of  the  eyelashes  and  lead 
to  them.  Anatomically,  they  are  here  called  the  glands 
of  Zeiss. 

The  sty,  however,  is  differentiated  from  ordinary 
acne  by  the  fact  that,  although  a  harmless  affection, 
it  causes  many  more  symptoms  and  more  inconvenience 
and  pain  than  acne, — due  to  the  anatomic  structure  of 
its  site. 

Usually  the  first  symptom  of  the  coining  hordeolimi 
is  a  diffuse  swelling  and  redness  of  the  whole  lid  with 
a  sensation  of  tension  soon  becoming  painful.  Exam- 
ination of  the  lid  commonly  discloses  a  small  inflamed 
nodule  on  the  free  margin  between  or  in  front  of  the 
eyelashes,  hard  and  extremely  sensitive  to  the  touch. 
Extension  of  the  infiltration  from  the  glands  into  ad- 
jacent tissues  enlarges  the  nodule  which  may  become 
the  size  of  a  pea  or  larger.  As  a  rule,  the  palpebral 
skin  is  very  red,  the  lid  swollen  and  there  is  consid- 
erable pain  so  that  the  slight  local  affection  may  be- 
come very  annoying.  After  a  few  days  the  centre  of 
the  infiltration  develops  a  yellow  point  of  suppuration 
which  soon  breaks  externally  on  the  palpebral  mar- 

24 


Alias. 


Tab.  Xll. 


Fig.   15. 
Hordeolum 


ioilip.lny.  New  York 


gin;  the  pus  flows  out  and  there  is  healing  within  a 
few  days.  More  rarely  the  infiltration  extends  further 
into  the  palpebral  tissues  and  develops  severe  in- 
flammation somewhat  like  a  furimcle.  In  such  cases 
the  inflammatory  phenomena  may  be  quite  violent  and 
we  have  chemosis  and  marked  infiltration  of  the  pal- 
pebral and  bulbar  conjunctivae  as  well  as  tmnefaction 
of  the  Ud. 

The  course  is  always  rapid  and  favorable.  Later, 
only  close  observation  detects  the  slight  scar  left  by 
the  preceding  disorder. 

Dlag'nosis  at  first  is  not  always  easy,  for  the  vio- 
lent onset,  the  considerable  and  rapid  swelling  and  the 
pains  might  presuppose  some  grave  affection  of  the 
eye.  A  sty  is  to  be  suspected  as  soon  as  it  is  ascer- 
tained that  the  cornea  is  clear,  the  pericorneal  tissue 
not  injected,  and  the  conjunctival  sac  free  from  ab- 
normal secretions,  thereby  excluding  a  commencing 
blenorrhea  as  well  as  a  deeper-seated  morbidity  (pan- 
ophthalmia). It  will  not  be  long  before  a  small  in- 
flamed nodule  will  be  found  near  the  palpebral  margin, 
rendering  the  diagnosis  certain.  If  the  finger  be  gent- 
ly passed  over  the  surface  of  the  lid,  it  often  locates 
the  swollen,  painful  spot. 

The  hordeolum  generally  occurs  in  youth,  from  12  to 
25  years,  seldom  after  this  period.  Its  genesis  is 
favored  by  an  often  insignificant  chronic  blepharitis, 
which  has  given  the  micro-organisms  (sometimes 
hyphomycetic)  always  present  and  abundant  on  the 
palpebral  margin  opportunity  to  multiply  enormously, 
penetrating  and  occluding  the  excretory  ducts  of  the 
hair  follicles.  The  stasis  of  their  secretion  together 
with  bacterial  activity  soon  develops  suppuration. 

Therapy.  When  the  process  is  incipient  an  at- 
tempt may  be  made  to  scatter  the  infiltration  by  warm 

25 


compresses  before  the  glands  develop  suppuration. 
This  is  rarely  successful,  yet  the  warm  applications 
are  commendable,  for  they  lessen  the  tension  and 
swelling  of  the  lids,  diminish  the  pain,  and  aid  and 
accelerate  the  breaking  through  the  skin  of  the  pus. 
Warm  or  hot  cotton  compresses  dipped  into  a  2-4% 
boric  acid  solution  are  well  borne  by  the  eye,  usually 
afford  much  relief  and  are  much  better  than  the  or- 
dinary applications  of  chamomile  tea  or  lead-water 
which  often  contain  impurities  or  throw  down  a  pre- 
cipitate. The  compress  is  applied  several  times  dur- 
ing the  day  for  a  quarter  or  half  hour.  If  the  patient 
remain  in  the  house  it  is  advisable  to  wear  contin- 
uously a  warm  moist  compress  protected  by  rubber 
tissue,  which  will  keep  it  moist  6  to  12  hours.  At 
night  this  may  be  renewed  and  a  bandage  applied  to 
hold  it  in  place.  If  spontaneous  rupture  occur,  the 
cavity  should  be  well  emptied,  applying,  if  necessary, 
pressure  with  the  finger,  after  which  the  slight  wound 
soon  heals.  If  the  rupture  delay  too  long  and  the  pa- 
tient desires  freedom  from  the  annoying  pain,  a  small 
cut  with  a  lancet  point  may  be  made  perpendicular  to 
the  focus  of  infiltration  on  the  margin  of  the  lid  and 
pus  squeezed  out,  thus  materially  shortening  the  pro- 
cess. After  evacuation  the  pains  mostly  vanish  and 
the  inflammation  recedes  rapidly.  In  such  case  the 
moist  compress  should  be  continued  for  another  24 
hours. 

The  task  now  before  us  is  to  combat  the  so  frequent 
relapses  or  implication  of  other  hair  follicles.  It 
should  first  be  determined  if  there  be  a  chronic  ble- 
pharitis. This,  naturally,  demands  treatment,  and  the 
patient  should  also  be  warned  to  avoid  for  some  time 
such  external  harmful  influences  as  impure  air,  to- 
bacco smoke,  coal-dust,  etc.  Before  retiring  at  night 
the  eyes  should  be  cleansed  with  a  cloth  wet  with  some 

26 


collyrium,  e.  g.  lotio  Knmmerfeld,  or,  a  thin  layer  of 
white  precipitate  ointment  may  be  applied  to  the  lids. 
In  obstinate  cases,  paint  the  palpebral  margin  once 
daily  with  a  1%  solution  of  silver  nitrate. 


27 


Chalazion. 

Plate  XIH.,  Figs.  16-17. 

By  chalazion  or  Meibomian  cyst  (Hagelkorn)  is 
meant  a  circmnscribed  swelling  on  the  inner  surface 
of  the  eyelid  beneath  the  conjunctiva.  Its  starting- 
point  is  a  Meibomian  gland  lying  in  the  tarsus  under 
the  conjunctiva  and  hence  the  chalazion  develops  from 
the  tarsus.  The  Meibomian  glands  are  merely  modi- 
fications of  the  sebaceous  glands  of  the  external  skin 
to  which  they  are  similar  in  histologic  structure. 
Hence,  pathologic  processes  in  both  species  are  much 
alike. 

Chalazion  is  a  chronic  affection  of  the  Meibo- 
mian glands,  developing  slowly  with  almost  no  in- 
flammatory symptoms,  and  possibly  remaining  un- 
changed for  years.  During  a  period  of  months  a 
small  nodule  grows  in  the  palpebral  tissue,  at  first 
causing  no  trouble  and  hence  noticed  by  the  patient 
only  after  it  has  attained  some  size.  The  lid  is  not 
reddened  and  the  skin  remains  normal.  If  the  tumor 
be  minute,  so  that  nothing  is  observable  on  the  outer 
surface  of  the  lid,  the  finger  discovers  the  small 
spheric  growth  beneath  the  skin  which  is  movable 
over  it.  Since  the  chalazion  always  develops  in  the 
tarsal  cartilage,  it  is  always  mobile  with  the  cartilage, 
not  upon  it.  In  the  course  of  time  the  growths  may 
become  as  large  as  peas,  cherry-pits  or  beans.  They 
cause  then  a  palpebral  deformity,  particularly  when, 
as  is  often  the  case,  there  is  multiple  formation,  and 
the  shot-like  nodules  may  be  seen  from  afar  protrud- 

28 


u 


o 
o 


nan  Company,  New  York. 


ing  outward  beneath  the  skin.  Even  in  this  stadium 
inflammation  of  the  lid  or  pain  is  absent.  If  the  lid 
become  ectropic,  a  condition  often  aggravated  by  the 
stiffness  of  the  palpebral  tissue,  we  note  a  more  or  less 
prominent  yellow-brown  or  slate-gray  fleck  with  a 
reddened  areola  in  the  conjunctiva  projecting  into  the 
eye.  This  may  finally  break  through  the  conjunctiva, 
after  which  a  somewhat  thick,  slimy  fluid  exudes  from 
time  to  time  and  the  tumor  decreases  somewhat  in 
size.  Its  major  portion,  however,  composed  of  firmer 
granulation  tissue,  remains  in  its  capsule  imchanged. 
In  the  course  of  months  or  years  even  these  masses 
may  so  shrink  or  resorb  that  the  tumor  disappears. 

The  chalazion  is  usually  noted  in  adults,  seldom  de- 
veloping in  children.  Generally,  there  are  several  on 
one  lid,  or,  all  the  lids  are  deformed  by  these  lumps. 
In  the  beginning  they  cause  little  trouble,  but  in  the 
advanced  stage  are  disfiguring  and  either  by  the  de- 
velopment of  inflammatory  symptoms,  or  by  mechan- 
ical hindrance  to  the  movement  of  lid  and  eye  greatly 
annoy  their  possessor. 

Chalazia  develop  mostly  where  there  exists  a  slight 
but  chronic  conjimctivitis,  leading  to  occlusion  of  the 
excretory  ducts  of  the  Meibomian  glands  and  reten- 
tion of  their  secretions.  The  content  of  the  gland  then 
becomes  thickened  and  harder  and  may  change  by 
deposition  of  calcareous  salts  into  a  hard,  chalky  mass 
(calcareous  infarct  of  the  Meibomian  gland  or  lithiasis 
palpebralis).  These  are  seen  beneath  the  palpebral 
conjunctiva  as  small  white  or  bright  yellow  spots.  In 
fact,  calcareous  infarcts  of  the  Meibomian  glands  are 
frequently  prodromal  of  chalazia,  and  are  usually 
noted  in  considerable  number  surrounding  a  chalazion 
beneath  the  conjunctiva  of  the  same  lid.  These  thick- 
ened masses  of  glandular  secretion  may  exert  an  in- 
flammatory action  upon  the  endothelium  and  adjacent 

29 


tissues,  because  of  which  these  begin  to  proliferate  and 
become  infiltrated  with  small  cells.  With  the  progress 
of  such  infiltration,  the  mass  develops  into  a  dense 
granulation  tissue  in  which,  sometimes,  even  giant 
cells  are  found.  The  center  of  this  granulation  tumor, 
deprived  of  vascular  supply,  may  finally  disintegrate 
and  pass  into  mucoid  degeneration.  A  dense,  tough 
capsule,  foimed  of  the  surrounding  tarsal  tissue  under 
pressure,  commonly  develops  about  such  a  mass,  and 
the  chalazion,  therefore,  is  composed  of  tough,  dense 
granulation  tissue  enclosed  in  a  fibrous  connective  tis- 
sue capsule. 

Recently  it  has  been  maintained  by  several  authors 
that  the  chalazion  is,  as  a  rule,  tuberculous  in  nature, 
a  statement  which  has  been  further  supported  by  the 
demonstration  of  numerous  giant  cells  in  its  tissues. 
Many  investigations,  however,  prove  the  fallacy 
of  such  assertion,  at  least  in  the  majority  of  cases,  and 
the  benign  clinical  course  scarcely  bespeaks  a  tuber- 
culous process. 

Tlierapy.  At  the  beginning  and  as  long  as  the 
chalazia  remain  small,  we  may  try  to  scatter  them  by 
external  means,  e.  g.,  by  rubbing  an  ung.  potass,  iod. 
into  the  conjunctival  sac  or  by  painting  the  external 
skin  with  tr.  iod.  If  this  have  no  effect,  small,  hard 
chalazia  may  be  left  undisturbed.  If  they  grow  or 
are  already  so  large  as  to  be  disfigurative,  operation 
is  indicated. 

The  query  at  once  arises  whether  the  incision  shall 
be  dermal  or  conjunctival.  Although  the  protrusion 
is  mostly  outwards,  the  skin  should  never  be  incised. 
The  natural  opening  is  inward,  toward  the  conjunctiva, 
and  by  this  path  the  tumor-masses  are  most  easily 
reached  and  there  results  minimal  deformity  from  the 
operation.    The  operation  is  not  so  easy  and  simple  as 

30 


it  might  seem,  for  a  single  incision  does  not  suflSce  and 
the  removal  of  the  tough  tissue  is  essential  and  often 
diflScult.  The  first  cut,  therefore,  should  by  no  means 
be  too  small  or  superficial.  Its  direction  should  be 
parallel  to  the  palpebral  margin. 

As  the  operation  is  painful,  we  anesthetize  by  plac- 
ing in  the  conjunctival  sac  three  or  four  times  at  min- 
ute intervals  some  drops  of  a  2-4%  solution  of  cocain, 
or,  better  yet,  by  injecting  with  a  Pravaz  syringe  a 
few  drops  subcutaneously  at  the  site  of  the  tumor. 
The  ectropic  lid  is  best  fixed  with  a  blepharostat,  the 
conjunctiva  is  divided  with  the  knife  down  to  the  cap- 
sule and  we  endeavor  to  dissect  out  with  forcep  and 
scissors  the  encapsulated  node.  This  is  not  always 
easy  for  the  capsule  is  apt  to  be  firmly  attached  to  the 
surrounding  tissues.  If  it  cannot  be  shelled  out  in  its 
entirety,  as  much  as  possible  is  cut  out  with  scissors 
and  forcep  and  the  remainder  removed  with  the  sharp 
curette. 

To  avoid  relapses  and  the  formation  of  new  cha- 
lazia, a  chronic  conjunctivitis  present  must  be  treated 
and  cured.  If  white  calcareous  infarcts  of  the  Mei- 
bomian glands  are  noted,  so  that  a  number  of  excre- 
tory ducts  are  occluded,  the  glands  must  be  slit  open 
by  passing  a  cataract  needle  down  through  the  con- 
junctiva until  the  calcareous  mass  is  exposed,  when 
the  infarct  mav  be  removed  with  a  fine  curette. 


31 


Blepharitis  Marginalis. 

Plate  XIII.,  Fig.  16;  Pi^te  III.,  Fig.  3;  Plate  XIV., 

Fig.  18;  Plate  XXVIII.,  Fig.  41;  Plate  XXIX., 

Fig.  42. 

The  various  affections  of  the  palpebral  margin 
which  begin  with  symptoms  of  an  inflammatory  na- 
ture, we  term  blepharitis  marginalis.  They  belong 
to  the  most  common  diseases  of  the  eye  seen  by  the 
general  practician,  particularly  in  the  larger  cities  and 
among  the  poorer  classes  where  the  anemic  and  scro- 
fulous children  compose  a  majority  of  such  patients. 
The  skin  of  the  body  becomes  very  thin  and  delicate 
on  the  eyelids  and  still  more  so  as  it  approaches  the 
margins  so  that  here  we  have  the  most  tenuous  and 
sensitive  derm  of  the  whole  body.  For  this  reason, 
it  is  easily  comprehended  that  in  the  most  various 
dermal  diseases,  particularly  if  located  on  the  face 
and  extending  therefrom,  we  often  find  the  palpebral 
margin  particularly  inclined  to  sympathetic  complica- 
tion. The  various  skin  troubles  appearing  on  the  eye- 
lid and  its  mai-gin  are  not,  as  a  rule,  differentiable 
from  the  adjacent  foci  of  disease  and  should  receive 
similar  treatment,  in  regard  to  which  special  works 
are  to  be  consulted. 

There  frequently  appear,  however,  on  the  margin  of 
the  lid  characteristic  types  of  inflammation  which  here 
demand  special  consideration. 

Firstly,  we  should  differentiate  from  true  inflamma- 
tions of  the  palpebral  margin,  a  hyperemia  of  the  part, 
well-termed  blepharitis  vasomotoria. 

32 


Hyperemia  marginalis.  In  many  delicate-skinned 
individuals,  and  particularly  in  the  blond,  the 
marginal  skin  is  so  sensitive  that  it  becomes  very  red 
from  the  least  external  stimulus  or  irritation.  As  soon 
as  these  patients  enter  an  atmosphere  of  tobacco 
smoke  or  go  out  in  windy  weather  or  are  exposed  to 
a  strong  light,  they  develop  the  ugly  "red  eyelids" 
within  a  few  hours  or  the  next  morning.  The  phe- 
nomenon not  only  disfigures,  thus  often  spoiling  the 
patient's  enjoyment  of  some  harmless  pleasure,  but  is 
also  accompanied  by  many  inconveniences.  The  eyes 
itch  and  burn,  forcing  the  patient  to  rub  the  margins 
of  the  lids,  and  furthermore  there  is  a  sensation  of 
weight  and  heat  in  the  eyes  often  extremely  annoying 
when  engaged  in  diflBcult  work.  Often  it  requires  no 
external  irritant  to  evoke  the  troublesome  symptoms 
which  may  be  caused  by  unusual  bodily  exertion,  over- 
use of  the  eyes,  emotional  disturbances,  etc.  If  we 
consider  that  in  most  individuals,  excesses,  a  night's 
carouse,  long  exposure  to  impure  air  laden  with  to- 
bacco fumes  are  quite  evident  in  the  eyes  the  morning 
after,  it  is  comprehensible  how  vexatious  it  is  for 
most  youthful  patients  with  hypersensitive  margins 
of  the  eyelids  to  go  about  after  the  least  indiscretion 
with  swimming,  reddened  eyes  which  seem  to  betray 
an  over-indulgence  in  alcohol  or  a  night  spent  in  tears. 
Not  infrequently  the  insignificant  affection  hinders 
them  in  business. 

In  acute  attacks,  the  margins  of  both  lids  are  much 
reddened  and  if  closely  observed,  there  will  be  found 
in  the  redness  a  number  of  delicate,  bright-red,  deep- 
ly-injected blood-vessels.  Coexistent  there  is  often 
present  a  slight  swelling  of  the  lids  and  an  injected 
palpebral  conjunctiva.  Scale  formation  on  the  mar- 
gin of  the  lid  or  at  the  roots  of  the  lashes  is  usually 
lacking,  but  the  lacrimal  secretion  is,  as  a  rule,  in- 
creased, so  that  the  eye  "swims  in  tears." 

33 


If  the  trouble  has  been  of  some  duration,  the  acute 
attacks,  at  first  often  repeated,  develop  a  chronic  con- 
dition, i.  e.  the  lids  remain  red  and  their  margins  be- 
come thickened  and  heavy.  Many  thick,  distended 
blood-vessels  are  seen  in  the  palpebral  edge  which 
passes  from  a  red  to  a  violet  tint.  The  patient  devel- 
ops great  photophobia,  and,  because  of  the  ocular 
trouble,  have  to  be  extremely  careful  of  themselves. 
Even  at  some  distance  the  ugly  red  margins  are  vis- 
ible. 

The  affection,  at  first  insignificant,  is  most  persist- 
ent, and  in  many  instances  resists  treatment  for  a  long 
while.  Therapy  must  be  both  general  and  local.  It 
is  most  important  to  strengthen  and  harden  the  young, 
delicate,  often  anemic  or  scrofulous  individuals  in 
whom  the  trouble  first  begins.  Although  it  is  neces- 
sary to  warn  against  excesses,  over-exertion,  late  re- 
tiring, too  long  reading,  exposure  to  impure  air,  it  is 
equally  essential  to  avoid  coddling.  On  the  contrary, 
these  patients  should  be  as  much  as  possible  in  the 
fresh,  open  air,  and,  healthful  exercise,  cold  affusions 
with  vigorous  massage,  bathing  out  of  doors  will  in 
time  strengthen  the  organism  and  harden  the  sensi- 
tive skin.  Tonics  such  as  quinine,  iron,  etc.,  may  be 
given  internally. 

Locally,  the  parts  should  be  kept  clean,  and  cold 
compresses  of  some  mild  astringent,  such  as  lead- 
water,  very  weak  solution  of  tannic  acid,  water  con- 
taining a  few  drops  of  eau  de  Cologne  or  ethyl  alcohol 
are  to  be  commended.  Whatever  the  agent,  care  should 
be  taken  that  the  sensitive  parts  be  not  irritated  too 
much,  and  strongly  concentrated  solutions  are  to  be 
avoided.  The  eye-douche  is  very  useful  and  should 
be  employed  once  daily  or  every  second  day,  a  finely 
divided  and  not  too  forcible  stream  being  directed  for 
3-6  minutes  against  the  edges  of  the  gently  closed  lids. 

34 


To  the  douche  may  be  added  any  suitable  astringent 
and  hardening  agent  (eau  de  Cologne,  alcohol,  borax). 

Salves  are  best  dispensed  with,  for  the  ordinary  un- 
guents are  much  too  irritant.  If  the  skin  of  the  lids 
shows  a  tendency  to  chap  or  crack,  a  very  thin  film  of 
pure  lanolin  may  be  applied  at  night  before  retiring. 

In  obstinate  cases,  the  margin  may  be  painted  with 
a  1%  solution  of  silver  nitrate  or  2-3  superficial  appli- 
cation made  of  lapis  mitigatus  in  substance. 

Of  inflammations  of  the  palpebral  margin,  we  have 
two  chief  types  for  differentiation : 

1.  Blepharitis  marginalis  sicca,  also  called  blepha- 
radenitis,  seborrhea  marginalis,  blepharitis  squamosa, 
is  a  condition  of  hypersecretion  from  inflammatory  ir- 
ritation of  the  sebaceous  glands  of  the  palpebral  mar- 
gin, and  hence,  more  exactly,  a  seborrhea  of  the  ciliary 
portion  of  the  eyelid.  The  sebum  soon  dries  and  forms 
small  scales  lying  between  the  eyelashes  upon  the 
skin  of  the  lid.  Recent  investigations  have  dem- 
onstrated that  these  scales  are  not  altogether  the  prod- 
uct of  desiccatetd  sebum  and  dead,  cast-off  epidermal 
squams,  but  that  numerous  hyphomycetes  and  their 
colonies  found  on  the  margin  of  the  lid  and  in  the  ex- 
cretory ducts  of  the  glands  probably  engender  the  dis- 
ease in  most  instances. 

The  patient  is  usually  di'iven  to  the  physician  be- 
cause of  a  continual  itching  and  burning.  If  the  mar- 
gin of  the  lid  be  superficially  examined,  little  that  is 
abnormal  is  observed,  but  on  closer  investigation,  or 
if  one  rub  the  finger  firmly  across  the  eyelashes,  tho 
numberless  minute,  whitish-gray  scales  lying  upon  the 
margin  of  the  lid  at  the  roots  of  the  lashes  will  come 
into  evidence.  After  such  dry  massage,  the  palpebral 
margin  looks  as  if  powdered  with  flour,  and  by  such 
pulling  and  rubbing  the  lashes  may  be  dusted  off.  Un- 
derneath the  scales  the  margin  of  the  lid  is  reddened 

35 


but  not  ulcerated.  The  cilia  are  loosely  rooted  and 
easily  removed,  but  in  recent  cases  grow  in  again  as 
before.  When  the  condition  has  been  of  longer  dura- 
tion, the  eyelashes  are  affected,  lose  their  luster,  be- 
come bent  and  twisted  and  finally  fall  out.  Formation 
of  crusts  or  scabs  with  a  glueing  together  of  the  lash- 
es seldom  occurs.  In  such  case,  the  crusts  are  chiefly 
composed  of  the  dried  mucous  secretions  of  the  glands, 
and  beneath  them  (in  blepharitis  sicca)  there  is  no 
ulceration. 

In  therapy  it  is  to  be  well  understood  that  no  un- 
guent nor  any  other  remedy  is  of  the  slightest  value 
unless  before  each  application  all  scales  are  removed 
and  the  lid  margin  most  carefully  cleansed.  The  scales 
are  best  disposed  of  by  dropping  a  little  pure  olive 
oil  upon  the  margin  and  rubbing  it  in  between  the 
lashes.  After  a  few  minutes  the  scales  have  become 
loosened  and  may  be  removed  by  rubbing  with  a  piece 
of  flannel  and  using  ciliary  forceps  until  the  field  is 
clear.  Repetition  of  this  process  as  soon  as  new  scales 
are  formed  should  not  be  neglected  because  of  the 
slight,  transitory  swelling  and  redness  of  the  lid  mar- 
gin following  its  execution,  nor  is  any  harm  done  if 
some  lashes  fall  out;  when  loosely  rooted  they  come 
out  sooner  or  later,  growing  again  as  soon  as  the  mar- 
gin of  the  lid  becomes  healthy.  After  cleansing  and 
drying  the  parts,  a  portion  of  salve  the  size  of  a  pea 
is  rubbed  into  the  margin  with  a  glass  rod  or  the  fin- 
ger. Since  cleansing,  in  the  first  sittings,  somewhat 
irritates  the  eye,  it  is  best  done  once  a  day,  before  re- 
tiring. The  salve  remains  upon  the  margin  of  the 
lid  in  a  thin  layer  during  the  night,  and  is  washed  off 
in  the  morning  with  soap  and  water.  Suitable  oint- 
ments are  a  1  to  2%  img.  Pagenstecheri  (hydrarg.  oxyd. 
rubr.)  or  ung.  diach.  Hebrae,  best  attenuated  with  equal 

30 


quantities  of  vaseline.    Carefully  treated,  blepharitis 
sicca  is  not  obstinate  and  soon  heals,  without  sequelae. 

2.  Blepharitis  eczematosa  or  blepharitis  ulcerosa, 
scrophulosa,  is,  as  its  name  indicates,  an  eczema  of  the 
palpebral  margin,  and,  as  in  dermal  eczema,  exhibits 
the  most  varied  types. 

The  first  three  stadia  develop  rapidly,  as  a  rule,  or 
else  are  not  distinctly  observed  as  such;  the  fifth  sta- 
dium begins  in  an  eczema  already  in  the  process  of 
healing,  so  that  the  physician  is  best  acquainted  with 
the  fourth  stadium,  by  far  the  commonest  in  most 
cases,  the  stadium  of  moist  ulceration  and  crust-for- 
mation. 

Primarily  we  have  a  hyperemia  and  swelling  of  the 
lid  margin,  due  to  a  serious  saturation  of  tissues 
and  leucoeytic  emigration.  The  tumefaction  usually 
develops  in  spots  so  that  a  number  of  small,  dense  red 
nodules,  the  size  of  a  hempseed  or  pinhead  are  found 
on  the  margin  (stadium  papulosum). 

With  an  increasing  serous  infiltration,  the  epithe- 
litun  of  the  derm  is  raised  up  here  and  there  and  cir- 
cumscribed collections  of  fluid  form  between  the  epi- 
thelium and  the  rete  mucosum,  vesicles  filled  with  a 
clear  watery  fluid  (stadium  vesiculosum). 

Gradually  the  leucoeytic  emigration  augments  until 
the  contents  of  the  vesicle  become  more  and  more  tur- 
bid and  finally  purulent  (stadium  pustulosum). 

At  last  the  pustules  break  and  ulcers  form,  soon 
crusting  over.  Beneath  the  crusts  the  weeping  ulcers 
persist  unchanged  (stadium  madidans),  and  in  this 
state  the  disease  may  continue  for  a  long  time,  new 
vesicles  and  pustules  forming  in  the  neighborhood  of 
the  ulceration,  so  that  the  various  stadia  may  be  syn- 
chronously observed,  the  stadium  madidans  predom- 
inating. 

When  finally  the  inflammatory  phenomena  subside, 

37 


the  exudation  and  crust-formation  lessens.  The  ulcers 
heal,  and  epithelial  loss  is  no  longer  observed  on  the 
superficies  of  the  denn,  but,  the  skin  retains  for  some 
time  the  inclination  to  develop  inordinate  quantities 
of  epithelial  cells  which  rapidly  comify  and  are  cast 
off.  Hence,  we  find  the  affected  areas  covered  with 
layers  of  scales,  the  stadium  squamosum. 

As  mentioned  above,  the  physician  is  usually  con- 
fronted with  the  matured  eczema  in  the  fourth  sta- 
dium. The  margin  of  the  lid  is  markedly  swollen, 
thickened,  and  covered  with  crusts,  and  not  infre- 
quently vesicles  and  pustules  are  seen  in  the  neighbor- 
hood of  the  crusts.  The  pustules  are  most  commonly 
located  about  the  cilia,  and  when  they  rupture  the  sin- 
gle cilium  is  observed  rising  up  out  of  a  deep,  crater- 
like ulcer.  The  ulcers  soon  begin  to  exude,  and  thick 
crusts  form,  which,  if  removed,  expose  the  deep,  easily 
bleeding  ulcus.  If  the  disease  remain  untreated  the 
lashes  fall  out  and  do  not  return.  The  angle  of  the 
lid-margin  is  eaten  away  so  that  a  slight  eversion  re- 
sults. The  loss  of  the  cilia  is  due  to  the  fact  that  their 
follicles  have  been  destroyed  by  suppuration.  Where 
this  has  not  happened,  the  cilia  grow  again  through 
the  crusts  and  cicatrices,  but  pervertedly,  so  that  the 
eye  may  suffer  greatly  from  their  abnormal  positions 
(vide  Plate  XXII.,  Pig.  13).  Almost  invariably  the 
remainder  of  the  palpebral  skin  and  the  conjunctivae 
are  affected,  and  commonly  the  eczema  extends  to  the 
cheeks  or  nose.  Eczema  of  the  scalp  as  well  as  of  the 
eyelids  is  often  present.  The  nasal  cavities  should  be 
watched  most  carefully,  for  in  them  analogous  pro- 
cesses (eczema,  purulent  discharges,  ozena)  often  de- 
velop. 

As  the  cause  of  the  disease,  we  almost  invariably 
find  a  general  scrofulosis  and  tuberculosis.     The  in 
dividuals  affected  are  usually  frail,  poorly  nourished 

38 


children,  exhibiting  all  the  signs  of  scrofula  (eczema, 
glandular  swelling,  a  puffy,  bloated  appearance,  thick 
lips,  etc.)  More  rarely,  local  injurious  influences  (bad 
air,  dust,  occupation-noxae)  or  persistent  conjunctival 
irritation  from  epiphora  or  other  secretions  may  de- 
velop eczema  and  ulceration  of  the  palpebral  margins. 

The  diag-nosls  of  blepharitis  eczematosa  is  not 
difficult.  The  disease  is  differentiated  from  blepha- 
ritis sicca,  which  occasionally  begins  with  crust-for- 
mation, chiefly  by  the  fact  that  when  the  crusts  are 
removed,  the  deep  eczematous  ulcers  appear.  The 
eczema  might  be  confused  with  sycosis  (Bartflechte) 
which  sometimes  locates  on  the  margin  of  the  eyelid, 
but  in  sycosis  the  large,  exuding  areas  and  ulcerations 
are  absent.  Furthermore,  sycosis  develops  almost  in- 
variably in  adult  males,  whilst  blepharitis  eczematosa 
usually  affects  weakly  children. 

The  course  of  an  untreated  blepharitis  eczematosa 
is  extremely  chronic.  In  its  chronicity  it  passes  into 
a  stage  where  the  epithelial  layer  of  the  skin  becomes 
necrotic,  the  denuded  areas  covered  with  thick,  solid, 
yellow-brown  scabs,  and  in  this  state,  the  disease  may 
persist  for  years. 

With  long  continuance  of  the  affection,  the  eyes  suf- 
fer in  many  ways,  and  there  are  a  number  of  sequelae 
of  chronic  blepharitis  which  injure  the  visual  organs 
to  a  greater  or  less  degree,  e.  g. 

Chronic  conjunctivitis,  which  may  cause  much 
trouble. 

Destruction  of  the  cilia  and  the  margin  of  the  lid. 
The  hair  follicles  and  glands  become  implicated  in  the 
ulcerative  process  and  are  destroyed  by  suppuration. 
Finally,  all  of  the  lashes  fall  out  or  there  remain  only 
a  few.  The  lid-margin  breaks  down,  and  instead  of 
the  normal  rectangular   form,  its  delicate  edge  be- 

39 


comes  rounded  off,  so  that  some  portions  are  shrimk- 
en,  others  hypertrophic  and  thick. 

Trichiasis.  The  few  remaining  cilia  may  be  turned 
inward  by  cicatricial  contraction  and  thus  possibly 
abrade  the  cornea. 

Therapy  should  not  only  be  local,  but  constitu- 
tional. The  hygienic  environments  of  the  patient  are 
to  be  improved,  the  delicate  children  properly  nour- 
ished, moimtain  or  seashore  prescribed  when  condi- 
tions permit,  and  every  endeavor  made  to  vanquish  the 
existent  scrofulosis.  Internally,  cod-liver  oil,  iron, 
iodine,  etc.,  are  indicated,  and  for  the  habitual  obsti- 
pation often  present,  calomel  should  initiate  the  treat- 
ment. Above  all,  the  rarely  absent  nasal  complication 
must  be  cured,  for  as  long  as  it  is  present  an  ap- 
parently healed  eye  will  soon  become  diseased  again. 

Of  local  measures,  the  first  is  a  careful,  daily  re- 
moval of  the  crusts.  This  is  accomplished  by  loosen- 
ing them  with  warm  water,  or  still  better,  with  olive 
oil,  followed  by  rubbing  or  scratching  them  off  with 
blunt  forceps.  Loose  or  slanting  lashes  should  be  ex- 
tracted with  cilia  forceps.  One  should  not  be  fright- 
ened if  the  ulcers  beneath  the  crusts  bleed  easily  and 
reproduce  the  crusts.  In  the  first  days  of  treatment 
a  light  superficial  brushing-over  of  the  ulcer's  base 
with  the  mitigated  silver  nitrate  stick  (lapis  mitiga- 
tus)  is  often  helpful.  Unguental  treatment  is  partic- 
ularly applicable  in  this  disease,  and,  as  in  all  eczemas, 
care  must  be  taken  not  to  use  too  irritant  salves.  The 
choice  of  the  salve  is  not  of  so  much  consequence  as 
its  degree  of  concentration.  In  weeping  eczema  of  the 
eyelid  and  margin,  it  is  best  to  prepare  a  compress 
suggested  by  Hebra.  The  ointment  is  spread  thick 
upon  strips  of  boracic  gauze  and  these  applied  shingle- 
fashion  to  the  eye,  i.  e.  one  strip  overlying  the  strip 

40 


below.  In  order  not  to  annoy  the  patient  too  much, 
the  eyes  may  be  treated  in  alternation.  The  best  un- 
guent is  Hebra's  diachylon  salve;  the  white  and  red 
precipitate  ointments  are  often  used  but  it  is  wise  to 
prescribe  the  latter  in  less  strength  than  originally 
given  by  Pagenstecher.  Schreiber,  of  Magdeburg,  is 
very  successful  with  a  14%  ointment  of  silver  nitrate. 
A  1%  resorcin  unguent  is  recommended  where  the  eyes 
are  hypersensitive.  The  bandage  should  first  be 
changed  once,  later  twice  in  the  24  hours,  and  it  is  im- 
portant to  see  that  the  unguent  be  freshly  made  and 
its  base  not  rancid. 

This  unguental  treatment  generally  causes  the  ec- 
zema to  pass  from  the  stadium  madidans  into  the  sta- 
dium squamosum  or  desquamation,  when  it  should  be 
stopped,  the  affected  areas  of  skin  usually  healing 
soon  with  the  employment  of  a  dusting  powder. 

In  particularly  obstinate  or  chronic  eczemas,  a  tar 
treatment  after  the  unguental  is  often  advisable.  The 
affected  areas  are  painted  daily  with  pure  tar  or  with 
equal  parts  of  tar  and  olive  oil. 

With  needful  patience  on  the  part  of  patient  and 
physician  and  some  care  in  the  use  of  salves,  which  are 
not  equally  well  borne  by  all  patients,  it  is  possible  to 
overcome  the  most  obstinate  forms  of  the  disease. 


41 


Entropium. 

Plate  XIV.,  Fig.  18;  Plate  XXII.,  Fig.  31. 

In  entropium,  the  lid  or  its  margin  is  turned  in  so 
that  the  free  edge  and  the  lashes  no  longer  project 
outwards  but  lie  directly  against  the  eyeball,  upon 
which  the  cilia  rub  with  every  movement  of  the  lid, 
thus  causing  irritant  and  inflammatory  phenomena, 
i.  e.  they  act  like  foreign  bodies  upon  the  exterior  en- 
velope of  the  globe. 

Palpebral  entropium  is  differentiated  from  trichi- 
asis and  distichiasis  as  follows :  In  trichiasis  the  lash- 
es are  correctly  placed  but  the  margin  of  the  lid  bear- 
ing them  rolls  inward  toward  the  globe  whilst  in  dis- 
tichiasis, the  margin  lies  normally  but  the  cilia  grow 
crookedly  or  too  much  in  an  inward  direction  so  that 
they  impinge  upon  the  eyeball.  Frequently,  however, 
we  find  both  conditions  present:  misplacements  of 
margin  and  cilia. 

If  in  a  case  of  marked  entropium  we  look  directly 
at  the  eye,  the  edge  of  the  lid  is  scarcely  visible  and  it 
is  only  when  the  lid  is  pulled  outwards  by  the  fingers 
that  it  unrolls,  bringing  the  margin  into  view,  and, 
when  let  go,  it  rolls  in  again  and  the  margin  vanishes. 

The  entropium  may  involve  the  entire  lid,  or  por- 
tions only  may  be  turned  inwards,  a  partial  entropium. 
In  case  of  the  latter,  the  lower  lid  is  chiefly  affected  in 
the  middle  and  outer  third;  the  upper  lid  mostly  in 
the  outer  third.  Both  lids,  the  upper  and  the  lower, 
are  about  equally  subject  to  the  disease. 

Various  degrees  of  inversion  may  be  differentiated. 

42 


Atlas, 


Tab.  XIV. 


Fig.   18. 
Entropium  Trichiasis  following 
Conjunctivitis  simple.^  chronica. 


Company,  New  York 


In  the  minimal  degree  the  free  edge  of  the  lid  is  turned 
so  far  inward  that  the  tips  of  the  cilia  impinge  upon 
the  eyeball,  being  so  twisted  that  they  lie  nearly 
parallel  to  the  lid  margin  and  glide  tangentially  across 
the  globe.  If  the  lid  margin  is  turned  so  far  inward 
that  the  lashes  rest  directly  upon  the  eyeball,  they 
gradually  assume  a  position  the  reverse  of  natural, 
i.  e.  they  no  longer- curl  outward  but  are  bent  inward 
to  correspond  to  the  curve  of  the  eyeball  so  that  their 
tips  are  directed  away  frum  the  cornea  toward  the 
conjunctival  fornix.  In  the  maximal  degree  of  inver- 
sion, the  palpebral  skin  lies  against  the  globe  whilst 
the  cilia  penetrate  deeply  into  the  conjunctival  fornix. 

Entropium  always  results  in  injury  to  the  affected 
eye,  chiefly  caused  by  the  internally  directed  cilia. 
The  patient  has  the  sensation  of  a  foreign  body  in  the 
eye,  and  soon  there  develop  extreme  laerimation,  pho- 
sophobia,  conjunctival  and  pericorneal  injection.  If 
the  entropium  persist  for  some  time,  the  cornea,  in 
particulate,  suffers,  and  may  be  injured  permanently. 
Because  of  the  continual  irritation,  the  corneal  epi- 
thelia  become  indurated,  thickened  and  cloudy,  or,  it 
may  happen  that  the  epithelia  in  divers  areas  are  in- 
jured by  the  cilia,  and  if  opportunely  infected,  a  super- 
ficial ulcer  of  the  cornea  may  develop.  In  old  chronic 
cases,  the  cornea  is  generally  covered  with  pannus-like 
opacities  and  indurations. 

Inversion  of  the  lids  is  invariably  the  result  of  pre- 
vious definite  diseases  of  the  eye,  and  in  most  in- 
stances is  due  to  contraction  or  shriveling  of  conjunc- 
tival scar-tissue.  According  to  their  etiology  we  dif- 
ferentiate two  chief  forms  of  entropium: 

1.  Entropium  cicatriceura.,  where,  by  cicatricial  con- 
traction of  conjunctival  tissues,  the  margin  of  the  lid 
is  drawn  inwards,  the  scars  being  due,  generally,  to 
a  long-lasting  trachoma,  to  the  so-called  cicatricial  tra- 

43 


choma  {vide  Plate  XX.,  Fig.  31).  Each  trachoma 
granule  heals  cicatricially,  whence,  where  many  and 
recurrent  granules  have  occupied  the  palpebral  con- 
junctiva, the  conjunctival  tissue  still  left,  does  not 
sufiSce,  because  of  the  long,  radiating  scars  extending 
chiefly  in  a  horizontal  direction,  to  cover  without  ten- 
sion, the  entire  inner  surface  of  the  lid.  Consequently, 
the  lid  is  constricted  interiorly  from  above  downwards, 
and  the  punctum  mobile,  the  free  margin  of  the  lid,  is 
forced  to  yield  and  roll  inwards.  In  such  cases,  the 
cilia,  impinging  almost  entirely  upon  the  eyeball,  are 
no  longer  normal,  but  develop  as  long,  fine  hairs  or 
degenerate  into  short,  thick  stumps  (trichiasis).  The 
free  angular  margin  of  the  lid  is,  generally,  no  longer 
present,  having  been  rounded  off  or  quite  flattened  out. 

In  other  cases  the  conjunctival  scars  causing  the 
entropium  were  due  to  wounds  or  burns  or  cauteriza- 
tions. 

2.  Entropium  spasticum.  This  follows  spasmodic 
contraction  of  certain  fibers  in  the  musculus  orbicu- 
laris. To  elucidate  the  genesis  of  this  form  of  inver- 
sion, we  must  consider  briefly  the  structure  and  action 
of  this  muscle.  The  musculus  orbicularis  is  a  super- 
ficially extended  muscle  of  the  skin,  divisible  into  two 
portions.  The  first  or  inner  portion,  lying  within 
the  lid  itself,  extends  to  the  palpebral  fissure ;  which  it 
encircles,  and  is,  therefore,  called  the  portio  palpe- 
bralis.  The  second,  or  outer  portion,  extends  peri- 
pherally from  the  first  to  the  orbital  edge  and  adjacent 
parts  and,  hence,  is  dubbed  the  portio  orbitalis.  As 
a  rule  only  the  palpebral  portion  governs  the  move- 
ments of  the  lid;  the  orbital  portion  merely  draws  to- 
gether the  facial  derm  surrounding  the  eyes  and, 
therefore,  aids  in  firm  closure  of  the  lids.  The  fibres 
of  the  portio  palpebralis  have  a  double  curve:  1.  with 
a  concave  side  toward  the  palpebral  margin,  and  2. 

44 


with  a  concave  side  toward  the  eyeball,  corresponding 
to  its  curvature.  A  contraction  in  these  muscle  bun- 
dles would  result  in  straightening  out  both  curves  (to- 
ward the  concave  side),  thus  first  closing  the  lids  and, 
secondly,  pressing  them  against  the  eyeball.  If  now, 
from  any  cause,  there  develops  an  unequal  or  imbal- 
anced  contraction  in  the  fibers  of  the  orbicularis,  e.  g. 
so  that  the  fibers  at  the  lid  margin  are  contracted  or 
spasmodically  tense,  whilst  all  other  fibers  remain  lax, 
the  palpebral  fibers  overcome  the  others  and  roll  the 
margin  inwards.  To  accomplish  this,  however,  an- 
other factor  is  requisite,  namely,  that  the  palpebral 
derm  be  not  tense  but  loose  and  flabby.  Both  of  these 
conditions  are  often  present  in  elderly  individuals,  for 
which  reason,  entropium  spasticum  is  most  commonly 
found  in  this  class  of  patients  (entropium  spasticum 
senile),  particularly  where  the  eye  has  been  kept 
closed  for  some  time,  as  after  cataract  operations, 
when  it  oftener  occurs  and  becomes  a  very  troublesome 
complication. 

In  like  manner,  the  orbicularis  fibers  of  the  margin 
of  the  lid  gain  the  ascendancy  if  their  tension  be  not 
counterbalanced  by  a  normal  curvature  of  the  eyeball, 
which,  if  lacking,  almost  invariably  develops  inver- 
sion of  both  lids.  But,  even  after  the  retrogression 
of  the  bulbus  into  the  orbit,  often  occurring  in  ema- 
ciated seniles,  entropium  may  develop,  and  likewise 
after  a  shriveling  and  atrophy  of  the  bulbus. 

From  a  spasmodic  contraction  of  the  orbicularis 
(blepharospasmus)  found  particularly  in  children,  en- 
tropium may  be  engendered,  and  here  the  portio  orbi- 
talis  often  acts  so  violently  that  the  margins  of  the 
two  lids  are  pressed  against  each  other  until  finally 
one  of  them  rolls  inwards.  This  form  of  entropium 
spasticum  in  youthful  patients  affects  the  lower  lid 
alone. 
Therapy.     Entropium  in  old  people  due  to  the 

45 


pressure  of  a  bandage  commonly  disappears  when  the 
bandage  is  removed,  but,  if  for  other  reasons  it  is 
necessary  to  continue  the  compress,  we  may  endeavor 
to  hold  the  lid  in  its  normal  position  by  using  adhes- 
ive plaster  and  collodium,  the  application  beginning 
at  the  palpebral  edge  and  extending  downward  over 
the  cheek.  If  the  lid  be  not  kept  in  place  by  this 
method,  ligation  will  be  necessary. 

If  the  inversion  be  due  to  blepharospasmus,  this 
should  be  treated  and  cured,  after  which  the  entro- 
pium  disappears  of  itself. 

In  entropium  due  to  cicatricial  contractures,  it  is 
first  essential  to  remove  carefully  with  cilia  forceps 
all  the  eyelashes  impinging  upon  the  bulbus.  A  per- 
manent cure  is  attained  only  by  operation. 


46 


Atlas. 


Fig.   19. 
Lupus  vulgaris  faciei.     Narhenectropium. 


II  Company.  New  York 


Ectropium. 

Plate  XV.,  Fig.  19. 

By  ectropium  is  meant  an  anomalous  position  of  the 
Kds  where  they  with  their  conjunctivae  are  no  longer 
closely  appUed  to  the  bulbus  but  roll  outwards,  away 
from  it.  When  this  happens,  a  larger  or  smaller  area 
of  the  conjunctiva  may  lie  exposed  to  view.  There 
are  various  degrees  of  eversion,  from  the  slightest, 
where  the  palpebral  margin  does  not  quite  touch  the 
eyeball,  to  a  degree  where  the  whole  lid  is  turned  in- 
side out.  One  or  both  lids  may  be  affected;  most  com- 
monly, however,  only  the  lower. 

'  But,  even  with  a  minimal  eversion,  the  condition  is 
extremely  troublesome,  and  commonly  the  ectropium 
with  its  sequelae  soon  develop  a  state  of  great  irrita- 
tion in  the  eyeball.  Then,  with  the  separation  of  the 
lid  margin  from  the  globe,  the  lacrimal  puncta  are 
thrown  outwards  and  no  longer  drain  the  lacus  lacri- 
malis.  The  natural  transit  of  the  lacrimal  fluid  being 
thus  interfered  with,  the  tears  trickle  over  the  edge 
of  the  lid  and  down  the  cheeks,  and  we  have  epiphora. 

A  further  consequence  of  ectropium  is  the  inflam- 
mation and  hypertrophy  of  the  conjunctiva  thus  ex- 
posed to  external  irritants — air,  dust,  etc.  It  tumefies, 
and  the  swelUng  leads  to  yet  greater  eversion.  Thus, 
both  conditions  alternately  aggravate  each  other.  A 
high  degree  of  ectropium  may  finally  develop  grave 
consequences  for  the  eye,  since  the  cornea,  not  being 
adequately  covered  by  closure  of  the  lids,  invites  the 
development  of  a  keratitis  e  lagophthalmo. 

47 


According  to  their  etiology  we  differentiate  several 
species  of  ectropium: 

1.  Ectropium  paralyticum.  After  paralyses  of  the 
musculus  orbicularis,  e.  g.  as  a  complication  of  facial 
paralysis,  there  usually  develops  a  slight  eversion  of 
the  lower  lid,  explained  as  follows:  The  orbicularis 
whose  fibers  are  paralyzed  is  no  longer  able  to  hold 
the  lid  accurately  against  the  globe;  hence,  the  lid, 
obeying  the  law  of  gravitation,  sinks  down  and  some- 
what away  from  the  eyeball.  Because  of  this  mechan- 
ical genesis,  it  is  clear  that  the  lower  lid  alone  will  be 
affected. 

2.  Ectropium  senile.  This  form  is  very  similar  to 
the  one  just  described,  both  in  genesis  and  appear- 
ance, except  that  here  paralysis  is  not  etiologic  but 
rather  the  lax,  senile  skin  and  musculature  of  the  lid 
which  are  no  longer  able  to  hold  it  firmly  against  the 
globe.  The  lid  sinks  somewhat  down  and  outwards, 
and  there  develops  a  sulcus  betwixt  lid  and  globe  in 
which  the  exposed  conjunctiva  may  be  seen. 

3.  Ectropium  spasticum.  Pound  chiefly  in  children 
and  youthful  individuals  suffering  from  an  acute  con- 
junctivitis with  tumefaction,  particularly  when  accom- 
panied by  a  blepharospasm.  If,  with  such  children 
we  attempt  a  forcible  opening  of  the  eye,  it  happens 
that  by  a  strong  contraction  of  the  orbital  portion  of 
the  musculus  orbicularis  a  sudden  and  spontaneous 
eversion  of  both  lids  occurs.  This  may  also  be  excited 
by  simple  pressure  on  the  lids  without  touching  the 
eye.  For  the  development  of  an  ectropivmi  spasticum 
a  conjunctiva  well  tumefied  and  a  spasmodic  state  of 
the  musculus  orbicularis,  more  marked  in  the  portio 
orbitalis,  are  necessary.  If  such  a  suddenly  developed 
eversion  be  not  speedily  corrected,  the  already  swollen 
conjunctiva  will  be  strangulated  by  the  portio  palpe- 
bralis  of  the  orbicularis  and  marked  edematous  tume- 

48 


faction  will  ensue.  This  may  lead  to  permanent  ever- 
sion  until  the  conjunctivitis  has  been  cured.  Ectro- 
pium  spasticum  is  mostly  found  in  children  suffering 
from  a  scrofulous  conjunctivitis,  more  rarely  in  cases 
of  ophthalmia  neonatorum.  It  usually  affects  both 
lids  simultaneously,  and  may  attain  a  high  degree, 
so  that  the  bulbus  is  completely  hidden  by  the  swollen, 
everted  lids. 

Lesser  degrees  of  ectropium  may  develop  from  sim- 
ple swelling  of  the  conjunctiva,  which  becomes  not 
only  thicker  but  broader  and,  because  of  the  sausage- 
like tumefaction  of  the  palpebral  edge,  is  pushed  still 
further  away  from  the  globe  (ectropium  mechanicum). 
The  eversion  is  accentuated  when,  from  pinching  or  a 
spasmodic  statte,  there  is  contraction  of  the  palpebral 
portion  of  the  orbicular  muscle. 

4.  Ectropium  cicatriceum.  The  highest  degree  of 
eversion  is  caused  by  cicatricial  contractures.  This 
demands  that  a  portion  of  the  palpebral  edge  have 
been  destroyed  and  replaced  by  scar  tissue.  Such 
conditions  are  peculiarly  apt  to  develop  after  burns 
of  the  skin  of  the  lid  or  wounds  of  the  lid,  operations 
upon  the  cheek,  caries  of  the  orbital  edge,  etc.  The 
scar  formed  invariably  draws  the  margin  of  the  lid 
yet  farther  downwards  until  finally  the  entire  red- 
dened and  thickened  conjunctiva  of  the  lid  is  fully  ex- 
posed outwards,  and  of  the  lid  itself  only  the  edge, 
now  far  removed  from  the  globe,  is  visible. 

Tberapy.  The  earliest  possible  correction  of  the 
eversion  is  to  be  sought,  for  the  portion  of  conjunc- 
tival tissue  turned  outwards  is  continually  exposed  to 
the  air  and  the  dangerous  substances  contained  in  air, 
and  which  excite  violent  irritation  of  the  eye.  With 
increase  of  the  conjunctival  swelling,  the  eversion  aug- 
ments until  finally  a  circulus  vitiosus  is  developed. 

A  treatment  without  surgical  intervention  is  pos- 

49 


sible  only  in  ectropium  spasticmn.  Here,  in  the  be- 
ginning of  the  trouble,  the  everted  lids  may  be  re- 
placed without  much  diflSculty  and,  to  avoid  an  ever- 
ready  relapse,  they  should  be  kept  in  the  correct  posi- 
tion by  strips  of  adhesive  plaster  or  the  use  of  a  com- 
pression bandage. 

In  obstinate  cases,  an  extension  cut  of  the  external 
canthus  is  to  be  commended  before  the  correction  of 
the  eversion,  for  the  bleeding  caused  by  the  cut  is  very 
beneficial.  After  the  lids  are  replaced,  the  inflamma- 
tion and  swelling  of  the  conjunctiva  should  be  reduced. 

Other  forms  of  eversion  are  corrected  only  by  means 
of  the  ectropium  operation. 


50 


A(l:is. 


T;ib.  XVI. 


Fig.   20. 

Carcinoma  epitheliale  I. 


Ill  Conip.iny.  New  York. 


Carcinoma  Epitheliale 
Palpebrarum. 

Plate  XVI.,  Fig.  20;  Plate  XVII.,  Fig.  21. 

Carcinoma  is  the  commonest  palpebral  neoplasm. 
It  usually  occurs  as  a  shallow  ulcer,  scarcely  rising 
above  the  superficies  and  having  but  a  slightly  ele- 
vated wall-like  periphery.  Actual  tumors  are  few  in 
number.  The  flat,  slowly  extending  new  growth  is 
often  called  "ulcus  rodens,"  but  anatomically  it  is  a 
genuine  cancer  of  the  superficies. 

There  are  two  points  of  election  for  the  develop- 
ment of  palpebral  earcinomata,  first  the  inner  canthus 
where  we  have  a  junction  of  external  skin  and  con- 
junctiva. It  is  well  known  that  such  dermo-mucosal 
blendings  (the  margin  of  the  lips,  anus,  palpebral 
margin)  are  areas  of  predilection  for  carcinomatous 
genesis.  The  second  point  of  election  is  the  external 
derm  of  the  eyelid.  Carcinomata  developing  in  the 
first  mentioned  area  are  usually  more  malignant  and 
more  rapidly  and  deeply  destructive,  whilst  those  de- 
veloping in  the  palpebral  derm  are  mostly  benign  and 
therefore  of  the  ulcus  rodens  type. 

As  regards  localization  the  left  side  of  the  face  is 
more  often  affected  than  the  right.  It  is  also  certain 
that  the  neoplasm  is  much  commoner  on  the  lower  lid 
than  the  upper,  and  more  apt  to  be  found  in  the  in- 
ternal canthus  and,  as  first  remarked  by  Valude,  in 
the  neighborhood  of  the  lacrimal  sac.  Here  the  can- 
cerous process  penetrates  deeply  and  rapidly,  destroy- 
ing the  lacrimal  sac,  then  eroding  the  lacrimal  bone 

51 


and  extending  to  the  nasal  cavity,  or,  the  tumor  mass 
pushes  through  the  lacrimal  duct  into  the  nasal  fossa. 

Fig.  20  on  Plate  XVI.  shows  one  of  these  flat  dermal 
cancers  of  the  left  upper  lid  about  to  pass  over  the 
bridge  of  the  nose  to  the  other  side. 

The  growth  of  a  sxiperficial  carcinoma  on  the  eyelid 
may  be  extremely  slow,  sometimes  covering  a  period 
of  20  or  30  years  (Schulz-Zehden). 

Such  was  the  case  of  an  old  woman  in  the  Home  for 
Incurables,  of  whom  Dr.  Schulz-Zehden  (Berlin)  kind- 
ly permitted  a  wax  model  to  be  made,  shown  in 
Plate  XVII.,  Fig.  21.  The  cancer,  extending  from  the 
margin  of  the  lid,  had  existed  for  many  years.  It  had 
excavated  a  deep  hole  in  the  left  side  of  the  face, 
and  the  eyelids,  the  skin  of  forehead  and  cheek  and 
the  bony  margin  of  the  orbits  had  entirely  disap- 
peared. The  deep-simken,  shriveled  eyeball,  in  which 
the  cornea  is  distinctly  seen,  still  remains.  The  pa- 
tient had  invariably  refused  operation,  keeping  the 
eroded  area  covered  with  a  moist  cloth.  Recently, 
death  occurred,  and  when  we  consider  the  many  years 
of  its  existence,  the  slow  progress  of  the  carcinoma- 
tous growth  is  truly  remarkable. 

In  other  cases  the  nose  and  cheek  are  soon  impli- 
cated and  upon  them  the  growth  progresses  by  contin- 
uity. Occasionally,  however,  autopsy  alone  demon- 
strates how  extensively  the  adjacent  organs  and  cav- 
ities were  involved. 

Often  the  lymph  glands  remain  unaffected  for 
a  long  period.  Thiersch  observed  glandular  involve- 
ment in  two  instances  only;  Winiwarter,  in  26  cases, 
twice ;  Mayeda  in  his  series  of  195  carcinomata  of  this 
type,  found  eight  glandular  involvements,  a  percent- 
age of  4.1. 

In  general,  it  may  be  said  that  the  superficial  type 
does  not  develop  carcinomatous  processes  in  the 
glands  nor  metastasis  to  internal  organs. 

52 


Fig.  21. 
Carcinoma  epitheliale  palpebrariini 


man  Company.  New  York. 


Etiologieally,  we  need  only  remark  that  cancer  in 
this  region  frequently  arises  from  constant  irritation 
or  rubbing  of  warts ;  also  from  small  wounds,  cauter- 
ization, removal  of  vesicles,  nodules,  etc.,  and  possibly 
from  lupus. 

The  beginning  of  the  trouble  is  well  described  by 
Unna:  "Ulcus  rodens  commences  as  a  rose- red  or 
pearl-gray  nodule  the  size  of  a  mustard  seed,  rising 
a  millimeter  or  less  above  the  surrounding  surface, 
with  very  slow  peripheral  extension  and  the  develop- 
ment of  a  central  depression.  Thus,  there  are  found 
areas,  apparently  but  not  actually  cicatrized,  of  a 
gray-yellow  or  gray-red  color,  the  size  of  a  pea  or  cov- 
ering an  area  equal  to  that  of  a  dime  or  quarter-dollar, 
sometimes  oval  in  contour,  flat  and  lying  in  the  plane 
of  the  healthy  skin  or  slightly  depressed,  and  limited 
by  a  delicate,  ridge-like  margin  of  the  color  of  mother- 
of-pearl,  from  which  frequently  arise  minute  nodular 
thickenings.  Any  general  thickening  of  the  derm  or 
any  peripheral  inflammation  is  not  cognizable.  Even 
in  this  stadium  of  nodular  development,  slight  trau- 
mata of  various  parts  of  the  nodule,  usually  the  central 
portion,  result  in  desquamation  of  the  stratum  cor- 
neum,  and  a  dark  crust  or  scab,  formed  of  bloody  se- 
rum and  a  new  stratum  corneum,  develops.  Left  to 
itself,  this  crust  falls  off,  after  which  the  affection 
has  its  original  cicatrized  appearance.  Repeated 
desquamation  of  the  stratum  cornemn  finally  leads  to 
permanent  ulceration,  and  thus  the  second  or  ulcera- 
tive stadium  begins." 

Therapy  is  operative,  followed  eventually  by  a 
plastic  operation  upon  the  lid. 

Recently,  cures  with  the  Finsen  light  have  been  ob- 
tained. 

For  amelioration  of  pain,  the  ulcerated  areas  are 
covered  with  bandages  spread  with  unguent. 

53 


Dacryocystitis. 

Plate  XVIII.,  Figs.  22  and  23. 

Inflammation  of  the  lacrimal  sac  seldom  follows  a 
lesion  or  infection  of  the  conjunctiva  but  is  often  due 
to  some  ascending  nasal  affection,  to  stasis  and  de- 
composition of  the  lacrimal  fluid  above  a  stricture  or 
to  lesion  of  the  adjacent  bony  structures. 

Most  commonly  as  a  result  of  stricture  below,  the 
mucosa  of  the  lacrimal  sac  will  produce  abundant  pus 
which  flows  backwards  into  the  eye,  thus  presenting 
a  well  known  phenomenon  which  may  long  continue 
without  externally  visible  inflammatory  symptoms  of 
importance. 

The  best  name  for  the  malady  is,  therefore,  dacryo- 
cystitis chronica  and  not  dacryocystoblennorrhea.  If 
only  the  unfortunate  term,  blennorrhea  of  the  eye- 
applied  to  the  most  heterogenous  affections — could  be 
dropped!  Nowadays,  we  are  accustomed  to  differen- 
tiate etiologically,  and  this  should  be  done  whenever 
possible.  It  is  anything  but  conmiendable  to  Imnp 
together  trachoma,  gonococcal  infection,  pneumo- 
coccal infection,  and  pus  in  the  lacrimal  sac  under  the 
rubric  of  blennorrhea. 

The  chronic  lesion  of  the  lacrimal  sac  often  does 
not  betray  itself  externally  save  that  pus  is  frequently 
seen  in  the  eye.  If,  however,  pressure  is  made  upon 
the  lacrimal  sac  in  the  inner  canthus  where  it  is 
crossed  by  the  ligamentum  canthi  internum,  it  will  be 
seen  suddenly,  that  quantities  of  thick  -pus  are  exuding 
from  the  puncta  lacrimalia. 

54 


eff,  Atlas. 


Tab.  XVIII. 


Fig.  22.     Dacryo  -  Cystitis  acuta 


Fig.  23. 

Dacryo-Cystitis  witli  Fistula. 


1  Company,  New  York  , 


The  extreme  virulence  of  this  pus  from  the  lacrimal 
sac  was  known  long  before  bacteriologic  investiga- 
tions were  invented.  It  was  known  also  that  the  intact 
eyeball  might  be  long  exposed  to  the  regurgitant  pus 
from  the  lacrimal  sac  without  suffering  noticeable  in- 
jury, until  some  minute  lesion  of  the  cornea  permitted 
its  entrance.  Then  a  white  speck  developed  upon  the 
injured  superficies  of  the  cornea,  a  bacterial  coloniza- 
tion, from  which  an  ulcus  serpens  had  origin. 

In  pus  from  the  lacrimal  sac,  extremely  virulent 
pneumococci  are  usually  found,  sometimes  in  almost 
pure  culture. 

Such  chronic  lesion  of  the  sac  may  also  be  tubercu- 
lous, tubercles  or  tuberculous  ulcers  developing  in  the 
walls  of  the  cavity. 

It  is  likewise  frequent  in  chronic  trachoma,  tracho- 
ma follicles  being  found  in  the  sac  walls. 

Therapy.  This  should,  above  all  else,  be  directed 
against  the  often  etiologic  nasal  lesion.  To  cure  af- 
fections of  the  lacrimal  sac  and  duct,  the  pus  in  the  sac 
must  be  frequently  evacuated  by  pressure  with  the 
finger.  Then  the  superior  or  inferior  punctum  lacri- 
male  must  be  slit  or  enlarged  (with  a  Weber  knife) 
and,  after  the  introduction  of  an  Anel  syringe,  irriga- 
tion, first  with  disinfectant  and  then  with  astringent 
solutions,  should  be  practiced,  the  fluid  running 
through  the  nose  and  into  the  mouth.  If  these  injec- 
tions show  that  the  ductus  naso-lacrimalis  is  perme- 
able, but  constricted  in  places,  Bowman's  sounds  may 
be  used  in  gradual  dilatation. 

If  the  duct  be  completely  obliterated  or  if  the  use 
of  the  sounds  be  ineffectual,  the  radical  operation  or 
removal  of  the  sac  is  indicated. 

Congenital  Lesions  of  the  Lacrimal  Sac. 
Not  rarely,  pus  flows  from  the  lacrimal  sac  a  few 


days  after  birth.  The  source  of  the  purulency  is  easily 
overlooked,  and  the  diagnosis  made  of  blennorrhea 
neonatorum,  gonococcal  in  etiology.  This  condition  is 
often  seen  in  children  with  congenital  lues,  and  the 
suppuration  may  be  caused  by  a  neighboring  osseous 
lesion.  An  antisyphilitic  medication  often  suffices  for 
the  cure  of  the  trouble.  But  there  may  be  merely  a 
simple  retention  in  the  lacrimal  canal,  an  occlusion  in 
the  direction  of  the  nose,  and  no  real  blenorrhea,  in 
which  case  a  single  forcible  pressure  upon  the  dilated 
sac  may  open  the  channel  and  cause  the  recurrent  pus 
to  disappear. 

Acute  Dachyocystitis. 

The  syndrome  is  quite  different  when,  from  any 
cause,  the  pus  breaks  through  the  wall  of  the  sac,  for 
then  it  quickly  spreads  through  the  loose  adjacent  tis- 
sues, the  lids  swell  edematously  and  soon  we  have  a 
simple,  subcutaneous  furuncle  in  the  center  of  which 
lies  the  dilated  lacrimal  sac. 

A  case  of  this  sort  is  seen  in  Plate  XVIII.,  Fig.  22, 
to  which  the  name,  acute  dacryocystitis,  is  given  (ana- 
tomically, it  would  be  called  a  pericystitis  or  cystitis 
with  rupture). 

Diag'nosis  must  establish  where,  in  the  often 
marked  and  extensive  tumefaction  which  may  attack 
both  eyelid  and  cheek,  the  induration  is  located,  which, 
if  pressed  upon,  causes  pain.  It  is  noticeable  that  in 
the  region  of  greatest  swelling  there  is  frequently  a 
deep  horizontal  furrow  above  and  below  which  are  two 
turgid  red  elevations  {vide  Fig.  22).  The  furrow  is 
caused  by  the  ligamentum  canthi  internum  originating 
in  the  inner  canthus,  passing  over  the  lacrimal  sac 
and  inserted  into  the  lacrimal  bone. 

Therapy.  Warning  is  given  against  the  use  of 
injections  or  of  sounds  during  the  stadium  of  inflam- 

56 


mation,  the  result  of  which  would  be  extension  of  the 
infection  elsewhwere.  The  lesion  should  be  treated  as 
a  furuncle,  using  warm  compresses  and  poultices  and 
finally  making  a  wide  incision. 

If  not  dispersed,  the  pus  at  last  breaks  through  the 
external  skin  and  flows  out  {vide  Plate  XVIII.,  Fig. 
23),  after  which  the  lesion  usually  heals.  If  the  sup- 
puration still  continue,  it  is  commonly  due  to  caries  of 
the  lacrimal  bone.  The  wound  must  then  be  widely 
opened,  curetted,  and  packed  with  iodoform  gauze. 

After  the  healing  up  of  all  these  processes,  there 
may  still  remain  fistulae  of  the  lacrimal  sac. 


57 


Normal  Conjunctiva 
Palpebrarum. 

Plate  XIX.,  Fig.  24. 

The  conjunctiva  forms  a  sac  or  bag  slit  open  along 
the  line  of  the  palpebral  fissure,  at  the  margin  of 
which  it  is  transmuted,  without  demarcation,  into 
ordinary  skin.  In  the  conjunctival  sac  three  areas  are 
distinguished,  viz.:  1,  the  C.  palpebrarum;  2,  the  du- 
plication or  fold,  C.  fornicis;  3,  the  C.  bulbi  or  scler*. 

The  C.  palpebrarum  alone  has  the  properties  of 
true  mucosal  tissue,  and  hence  we  find  that  mucosal 
lesions,  e.  g.,  infections  such  as  gonorrhea,  diphtheria, 
etc.  as  well  as  follicular  affections,  develop  only  in  the 
conjunctiva  palpebrarum.  The  C.  bulbi  is  epidermal 
in  type,  and,  therefore,  dermal  lesions,  e.  g.  eczema- 
tous,  are  directly  bulbar  in  location. 

In  Plate  XIX.,  Fig.  24,  is  seen  the  conjunctiva  tarsi 
of  the  upper  lid  after  eversion.  The  mucosa  is  pale 
and  smooth  and  beneath  it,  the  glistening  yellowish 
Meibomian  glands  are  distinctly  visible. 


58 


ircL'fl.  Atlas 


liil).  .\l 


Fig.  24. 

Conjunctiva.     Normal  Condition. 


Fig.  25.     Conjunctivitis  catarrhalis  simplex. 


Rebniail  Company,  New  York. 


Conjunctivitis  Catarrhalis, 

Plate  XIX.,  Fig.  25. 

The  conjunctiva  is  a  delicate,  sensitive  tissue,  be- 
coming hyperemic  and  irritated  from  the  least  stimu- 
lus, e.  g.  exposure  to  air,  inundation  with  water  or 
the  salty  lacrimal  secretion,  entropium,  etc.  If  the 
irritation  continue  for  some  time  or  augment,  there 
develops  an  inflammation  of  the  membrane,  which 
may  exhibit  the  form  of  an  acute  or  chronic  catarrh. 
The  surface  of  the  swollen  and  inflamed  mucosa  does 
not  long  remain  smooth;  elevations  and  wrinklings 
are  soon  in  evidence  and  the  conjunctiva  presents  the 
appearance  of  a  piece  of  finely  granulated  leather  or 
clipped  velvet  (a  papillated  appearance,  vide  Plate 
XIX.,  Fig.  25),  actually  due  to  wrinkles  and  furrows 
in  the  tumefied  mucous  membrane. 

If  these  irregularities  increase  in  volume,  become 
cockscomb-like,  they  are  called  papillary  elevations, 
and  are  to  be  carefully  differentiated  from  follicles 
{vide  C.  follicularis,  infra). 

Acute  conjunctivitis  is  mostly  due  to  an  infection, 
whence  it  may  properly  be  termed,  conjunctivitis  in- 
fectiosa.  It  is  capable  of  transmission  and  sometimes 
excites  widespread  acute  epidemics  {cf.  in  contrast, 
the  behavior  of  trachoma,  often  confused  with  this 
affection).  Recent  baeteriologic  investigation  has 
taught  us  that  there  are  several  species  of  acute,  in- 
fectious conjunctivitis,  also  differentiable  clinically; 
e.  g.  conjunctivitis  caused  by  the  pneumococcus,  the 
Morax-Axenfeld  diplobacillus,  the  Koch- Weeks  bacil- 
lus, streptococci,  etc. 

59 


Chronic  conjunctivitis  is  due  either  to  external  noxae 
(dust,  smoke,  wind,  cold)  acting  upon  hypersensitive 
membranes  or  is  a  sequela  of  acute  infections. 

Therapy.  Our  treatment  is  directed  towards  dis- 
infection of  the  infected  mucosa,  and  the  lessening  of 
secretion  and  the  enormous  dilatation  of  the  blood- 
vessels by  means  of  astringents. 

Where  secretions  are  dammed  up,  micro-organisms 
multiply  rapidly,  and  nothing  is  more  senseless  than 
prolonged  bandaging  of  an  eye  endeavoring  to  rid 
itself  of  such  products.  On  the  contrary,  we  should 
seek  by  frequent  changing  of  compresses  and  by  irri- 
gation, to  provide  for  unhindered  secretion  and  its 
removal.  Since  the  conjunctiva  bears  well  both  the 
action  of  cold  and  cauterizing  agents,  we  choose  cold 
solutions  (water,  lead-water,  boric  acid,  sublimate 
1:5000,  etc.)  in  order  to  profit  by  the  synchronous  as- 
tringent effect  of  the  low  temperature. 

Medicaments  may  be  instilled  guttatim  into  the  con- 
junctival sac,  or,  after  eversion  of  the  lid  a  thick 
brush  dipped  into  the  solution  may  be  passed  over  the 
diseased  area.  The  following  drugs  are  commended: 
zinc  sulfur,  %  to  1  or  2%  ;  zinc  sozoiodol,  1/2  to  1%  ;  so- 
lution of  alima  1%  ;  sod.  sozoiodol,  3  to  6%  ;  resorcin,  1 
to  2%  ;  acid,  tannic,  1  to  2%.  In  purulent  secretions, 
the  sovereign  remedy  is  silver  nitrate,  1/5  to  1%  or  its 
substitutes  (protargol,  argentamin,  albargin,  etc.). 


60 


iff,  Atlas. 


u 


'^ 


'J5    C 


o 


man  Company,  New  York 


Conjunctivitis  Follicularis. 

Plate  XX.,  Fig.  26. 

Another  species  of  elevations  on  the  conjunctiva 
palpebrariun  is  the  follicular.  The  follicles  at  first 
resemble  transparent  vesicles ;  later,  and  in  malignant 
forms,  they  look  like  frog-spawn  or  cooked  sago 
grains,  and  are  composed  of  circumscribed  aggrega- 
tions of  round  cells  underneath  the  epithelium.  They 
are,  therefore,  neoplasmic,  comparable  to  lymph  folli- 
cles or  lymphomata,  and  develop  in  the  conjunctiva 
from  the  most  varied  stimuli  (chemical,  thermic,  bac- 
teriologic).  On  the  other  hand,  it  must  be  empha- 
sized that  not  every  stimulus  or  irritation  develops 
these  follicles,  nor  are  they  due  to  the  intensity  or  pro- 
longed action  of  the  irritation  but  to  its  specificity. 
Simple  chronic  catarrh,  however  long  its  duration, 
never  develops  follicles;  they  are  also  absent  in  the 
most  violent  conjunctival  inflammations  we  know,  viz. 
gonococcal  or  diphtheritic  infections.  Contrarily,  the 
formation  of  follicles  is  noted  in  a  large  number  of 
conjunctival  affections,  plainly  due  not  to  infection 
alone,  but  also  to  other  irritations.  The  various  spe- 
cies of  conjunctivitis  may,  therefore,  be  divided  into 
those  beginning  with  the  development  of  follicles,  and 
those  where  such  formation  is  absent. 

A  certain  percentage  of  children  with,  conjunctival 
follicles  are  found  in  all  schools,  but  the  conjunctiva  is 
pale  in  color  and  normal  and  the  condition  causes  no 
trouble.  In  such  cases,  diagnosis  of  conjunctivitis  fol- 
licularis is  incorrect,  for  there  is  no  conjunctivitis. 

61 


The  chlorotic  and  anemic  children  have  merely  dilated 
lymph  vessels  in  the  conjunctival  superficies, — lymph- 
ectasia.  Follicles  develop  whenever  numbers  of  indi- 
viduals are  crowded  together  in  a  heavy,  impure  air, 
as  in  overfilled  public  schools,  in  schoolrooms  espe- 
cially, in  orphan  asylums,  etc.  All  inmates  of  peni- 
tentiaries and  prisons  show,  post  mortem,  microscopic 
follicles  in  the  conjunctiva.  That  in  such  cases  symp- 
toms of  conjunctival  inflammation  are  usually  absent, 
is  due,  in  my  opinion,  to  the  fact  that,  as  a  rule,  it  is 
not  a  question  here  of  infection,  the  phenomenon 
being  due  to  the  irritant  atmosphere,  some  authorities 
attributing  it  to  the  ammoniacal  vapors,  others  to  the 
anthropotoxin  present,  etc. 

There  are,  however,  plainly  infectious  but  mild  con- 
junctivites  in  which  follicles  appear,  but,  generally,  not 
numerous,  superficially  located  and  chiefly  iB  the  lower 
lid.    These  follicles  disappear  without  leaving  scars. 

Therapy.  Sojourn  in  a  pure  atmosphere  and  ex- 
ercise in  the  open  air  often  suffice.  The  follicles  so 
often  found  in  school  children  frequently  disappear 
spontaneously  during  vacation.  In  addition,  the  eyes 
should  be  repeatedly  washed,  and  compresses  of  2-4% 
boracic  acid  solution  or  leadwater  applied.  For  in- 
stillation, Forster's  2%  solution  of  sod.  biboracicum  is 
best. 


62 


Fig.  28.    Conjunctivitis  trachomatosa 


Fig.  29.     Sklerosing  Traciioma. 


an  Company,  New  York. 


Conjunctivitis    Trachomatosa. 

Plate  XX.,  Fig.  27;  Plate  XXI.,  Figs.  28-29. 

Trachoma  is  an  infection  locating  in  the  mucosa  of 
the  lid,  and  is  indubitably  a  specific  morbid  entity, 
whose  cause  we  do  not  know  with  certainty.  It  is  not 
communicable  to  animals,  though  possibly  transmis- 
sible in  mild  form  to  the  anthropomorphous  apes. 

Trachoma  is  distinguished  by  the  formation  of  large 
follicles  which,  accompanied  by  inflammation  and 
marked  papillary  tumefaction,  constantly  increase  in 
size  and  number  and  finally  lead  to  necrosis  and  sub- 
epithelial shriveling. 

It  is  a  world-wide  disease,  but  its  occurrence  is  not 
symmetric,  i.  e.  in  regions  free  of  trachoma  are  found 
here  and  there  larger  or  smaller  areas  in  which  cases 
of  trachoma  are  always  numerous,  so-called  "tra- 
choma islets." 

Is  it  possible  to  differentiate  with  certainty  tracho- 
ma and  follicular  catarrh?  In  most  cases,  yes,  though 
at  first  not  always  without  error,  though  diagnosis 
may  be  invariably  established  by  more  extended  ob- 
servation. In  follicular  catarrh,  we  have  absolutely 
benign  new- formations,  usually  with  no  adjacent  in- 
flammation, no  reaction,  no  tumefaction,  and  which 
do  not  lead  to  any  notable  swelling  of  fornices  and 
papillae,  and  which,  in  contrast  to  trachoma,  prefer- 
ably develop  in  a  pale,  anemic  mucosa.  Their  lack 
of  malignancy  is  shown  by  the  fact  that  they  never 
lead  to  destruction  of  mucosal  tissue,  but  sooner  or 
later  disappear  spontaneously,  leaving  no  trace  of 
their  existence. 

63 


It  is  very  different  with  the  trachoma  granule.  It 
generally  presents  an  entirely  different  appearance, 
for,  whilst  the  follicular  granule  is  clear  and  pale,  more 
like  a  vesicle,  the  deeper-seated  grannie  of  trachoma 
soon  becomes  gray  and  discolored.  The  circumjacent 
mucosa  is  deeply  reddened,  tumefied  (so  that  the  tra- 
choma granule  seems  to  lie  deeper  below  the  surface) 
and  the  swollen  fomices,  when  the  lid  is  everted,  roll 
out  as  if  enlarged  and  thickened.  Very  soon  there 
develop  notable  papillary  proliferations,  indicative  of 
the  violent  reaction  excited  by  the  powerful  \'irus — 
phenomena  always  absent  in  follicular  catarrh.  In 
its  course,  the  malignant  character  of  trachoma  is 
made  perfectly  evident.  The  trachoma  granule  does 
not,  after  existing  for  some  time,  return  to  a  norm, 
but  is  distinguished  by  its  destructive  action  upon  the 
mucous  membrane.  It  tends  notably  toward  a  meta- 
morphosis of  the  mucosa  into  a  tough,  cicatricial  tis- 
sue and  develops  a  sort  of  cirrhosis,  similar  to  that 
caused  in  lung,  liver,  kidney  by  certain  inflammatory 
processes,  and  because  of  this  we  get  the  common  se- 
quelae of  trachoma.  The  cornea  is  often  implicated 
and  pannus  develops. 

Trachoma  is  at  the  present  time  a  pre-eminently 
chronic  disease,  endemic  in  many  regions,  absent  in 
others.  When  endemic,  it  pursues  its  course,  and, 
probably  has  for  centuries;  one  patient  after  another 
is  slowly  infected,  and,  of  a  family  of  six,  possibly 
three  are  trachomatous,  and,  gradually,  after  months 
or  years,  the  others  will  be.  The  transmission  is  not 
easily  accomplished,  and  continual,  prolonged  associ- 
ation with  those  infected,  a  common  use  of  sleeping 
places,  towels,  etc.,  are  requisite.  If  an  individual  is 
infected,  it  is  often  a  long  time  before  he  notices  the 
slightest  sign  of  inflammation,  and  it  may  be  months 
or  years  ere  the  process  becomes  malignant.     Some- 

64 


times,  however,  the  disease,  in  rare  and  isolated  cases, 
runs  a  violent  course.  If  a  patient  with  bad  trachoma 
enter  some  institution,  he  usually  infects,  after  some 
months,  a  greater  or  less  number  of  his  comrades,  and, 
in  this  manner  there  gradually  develops  a  small  en- 
demic. But,  I  have  never  found  all  the  inmates  of  such 
an  institution  affected,  which  is  proof  that  even  from 
long  and  daily  association  infection  need  not  follow. 
Trachoma,  therefore,  is  always  present  in  regions 
where  it  is  indigenous;  one  individual  after  another 
is  slowly  infected,  whilst  other  cases  recover,  so  that 
the  number  of  those  diseased  varies  within  certain 
limits;  some  years  perhaps  less,  other  years,  greater. 
But,  the  report  that  a  sudden  outbreak  of  trachoma 
has  occurred,  has  invariably  been  proven  false.  Either 
it  was  not  trachoma,  but  rapidly  spreading  innocuous 
catarrh  accompanied  by  tumefaction,  or  some  other 
disease,  or  else  in  the  regions  where  trachoma  had  ex- 
isted for  years,  attention  has  been  suddenly  fixed 
again  upon  the  disease. 

As  insidious  and  chronic  as  is  the  progress  of  tra- 
choma from  patient  to  patient,  so  is  its  course,  which 
if  not  interfered  with,  may  extend  over  years  or  even 
a  lifetime.  Quite  a  number  of  cases  finally  recover. 
But  even  the  best  treatment  must  cover  months,  and 
be  extremely  energetic,  if  a  sure  and  permanent  cure 
is  to  be  attained.  Relapses  are  very  frequent.  The 
disease  is  one  of  the  most  malignant  ophthalmic  dis- 
eases known,  and,  in  common  with  blenorrhea  neona- 
torum influences  largely  the  number  of  the  blind.  Still 
greater  is  the  number  of  patients  who,  while  not  en- 
tirely blind,  suffer  greatly  in  later  life  from  its  se- 
quel*. 

What  happens,  finally,  to  the  trachoma  granule? 

After  long  duration,  there  develops  always  in  its 
interior  a  sort  of  softening,  and  we  find  the  large  cells 

65 


in  the  stadium  of  necrosis,  the  nuclei  no  longer  stain- 
ing, until  at  last  there  is  left  only  a  granular,  crumbly 
mass  in  which  the  original  elements  have  vanished. 

In  many  cases,  the  softening  does  not  develop 
equally  throughout  the  contents  of  the  follicle  but 
begins  in  foci,  but  commonly  the  central  portion  is 
most  affected. 

The  most  typical  illustration  of  the  softened  follicle 
is  the  clinical  picture  of  the  so-called  gelatinous  tra- 
choma (Stellwag).  Here  the  follicular  formations 
stand  so  closely  together  that  the  single,  softened  fol- 
licles merge  into  one  jelly-like  mass  (Fig.  29). 

According  to  Ralilmann,  Addario  and  others,  the 
rupture  of  the  follicle  and  exudation  of  its  contents  is 
the  natural  termination. 

In  my  opinion,  the  gradual  resorption  of  the  follicu- 
lar contents  is  by  far  the  more  frequent  and  natural 
process.  This  resorption  is  found,  apparently,  not 
only  when  the  contents  are  softened,  but  according  to 
clinical  experience,  in  any  stadium.  Thus,  we  have 
seen  minute  follicles,  where  there  can  be  no  possible 
softening,  gradually  disappear  in  numerous  instances 
when  treated  medicamentally,  in  which  cases  there 
was  certainly  no  rupture  and  exudation  of  the  con- 
tents. 

For  the  therapy  of  trachoma,  consult  pp.  69-70. 


66 


Atlas. 


T.ib.  xxn 


Fig.  30.  Pannus  trachomatosus. 


Fig.  31.     Fntropium  and  Triciiiasis  tiirougli  scar-tissue. 


n  Company,  New  York. 


Pannus  Trachomatosus, 

Plate  XXII.,  Pigs.  30,  31 ;  Plate  XXIII.,  Figs.  32,  33. 

The  trachomatous  process  may  pass  from  the  con- 
junctiva palpebrarum  et  fornicis  to  the  cornea  with- 
out attacking  the  conjunctiva  bulbi,  and  upon  the  cor- 
nea develop  the  pannus  trachomatosus,  starting  al- 
most invariably  at  the  corneal  margin  and  usually 
from  the  upper  portion.  Here  are  seen  at  first,  small, 
circumscribed  elevations  demonstrable  only  with  a 
magnifying  glass, — minute  but  distinct  points  rising 
above  the  corneal  surface,  sometimes  attaining  the 
size  of  a  poppy-seed.  These  solid  nodules,  gray-white 
in  color  are  follicles,  circumscribed,  subepithelial  infil- 
trations of  clearly  defined  masses  of  Ijmiphoid  cells. 
If  the  nodules  already  lie  in  the  transparent  corneal 
tissue,  many  of  them  may  be  seen  surrounded  by 
slightly  cloudy  areola".  Later,  the  nodules  become 
confluent,  forming  a  soft,  diffuse  mass,  rich  in  cells, 
which,  subepithelially,  push  forward  from  the  superior 
margin  of  the  cornea  across  its  transparent  tissues. 
Since  tliis  neoplasmic  layer  is  not  everywhere  of  equal 
thickness,  the  overlying  epithelium  is  humped  up  here 
and  there.  As  soon,  however,  as  the  layer  has  pro- 
gressed a  millimeter  or  more  across  the  transparent 
cornea,  there  begins,  at  its  superior  edge,  a  vascular 
proliferation  extending  with  it  across  the  cornea  but 
always  somewhat  posterior  to  the  zone  of  infiltration. 
These  blood  vessels  do  not  all  extend  meridianly  to- 
ward the  center  of  the  cornea,  but  are  inclined  rather 
to  run  in  parallel  from  above  downward. 

67 


According  to  the  vascular  development,  the  pannus 
varies  in  appearance.  A  fresh  pannus,  with  few  of 
these  blood  vessels  extending  downwards,  is  called 
pannus  tenuis;  if  they  are  numerous,  pannus  vascu- 
losiis.  Sometimes,  the  new  tissue  becomes  so  thick 
and  vascular  that  it  appears  like  granulation-tissue 
or  raw  flesh  lying  upon  the  cornea,  and  is  then  termed 
pannus  crassus  or  carnosus;  less  suitably,  pannus  sar- 
comatosus. 

With  retrogression  of  the  growth,  the  zone  of  infec- 
tion first  recedes  and  the  blood  vessels  follow  the  vas- 
cularity, thus  always  remaining  longer  in  evidence 
{vide  Fig.  45).  Because  of  this,  the  progressing  and 
retrogressing  panni  are  always  easily  differentiated. 
As  soon  as  the  pannus  and  the  blood  vessels  have 
somewhat  passed  the  central  point  of  the  cornea,  the 
picture  changes.  The  blood  vessels  no  longer  run 
parallel  from  above  but  extend  in  all  directions  on  the 
corneal  surface,  in  whose  central  portion  they  fre- 
quently anastomose  and  form  varicose  swellings 
{vide  Fig.  46),  and  it  is  seen  from  their  more  indis- 
tinct, bluish  hue,  that  they  now  lie,  in  many  areas, 
deeper  in  the  tissues.  An  old  pannus,  with  connective 
tissue  metamorphosis,  has  usually  but  few  blood-ves- 
sels and  these  of  diminished  caliber:    pannus  siccus. 

Cicatricial  Trachoma. 

Finally,  and  commonly  after  persisting  for  years, 
the  trachoma  leads  to  a  more  or  less  extensive  cica- 
tricial contraction  of  the  affected  mucosa.  The  tarsus 
is,  as  a  rule,  implicated  later.  Its  tissues,  at  first 
densely  infiltrated,  exhibit  marked  tumefaction,  but, 
in  time  contract,  and  we  have  a  rigid,  sclerotic  invo- 
lution (Plate  XXni.,  Fig.  32). 

The  tarsal  distortion  is  typical  in  all  cases,  i.  e.  there 
is  not  equal  curvature  of  the  cartilage  but  a  percep- 

68 


Tab.  XXIII. 


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n  Company,  New  York, 


tible  notch  in  its  middle  portion.  It  is  easily  cognized 
that  the  callous  thickening  of  the  conjunctiva  is  great- 
est at  a  point  corresponding  to  this  notch,  so  that  here, 
in  a  fashion,  the  punctum  fixum  of  the  cicatricial  re- 
traction is  located,  because  of  which  the  two  cartilage 
margins  are  displaced  by  the  retractive  action  of  the 
scar.  Hence,  the  distorted,  trough-like  cartilage  is, 
because  correspondent  to  the  thickest  portion  of  the 
callous  conjunctival  cicatrix,  more  or  less  indented. 

With  the  inward  bending  of  the  tarsus,  the  free 
margin  of  the  lid  is  also  bent  inwards,  and  there  de- 
velops entropium  with  its  well  known  grave  sequelae 
(Fig.  31). 

If,  finally,  the  conjunctiva  becomes  so  cicatrized, 
that  the  cornea  is  no  longer  sufficiently  moistened,  the 
entire  surface  of  the  eyeball  becomes  rough,  dry,  epi- 
dermoid, a  condition  called  xerophthalmus  (Plate 
XXIII.,  Fig.  33). 

The  tberapy  of  trachoma.  We  have  medical,  me- 
chanical and  surgical  methods  of  treatment.  Of  medi- 
caments, two  are  pre-eminently  useful:  silver  nitrate 
in  2%  solution  in  new  cases,  particularly  where  the 
secretions  are  copious,  applied  with  a  brush  or  swab; 
and  copper  sulfate  where  the  resorption  of  follicles  is 
desired.  The  latter  is  best  used  in  the  crystal  form, 
the  so-called  blue-stone  or  pencil,  with  which  the  en- 
tire conjunctival  surface  is  gently  and  equably  stroked 
once  daily.  Cold  compresses  are  then  applied,  the  use 
of  the  stone  being  discontinued,  if  the  ophthalmic  con- 
dition exhibits  progressive  irritation.  If  the  patient 
is  not  seen  daily  by  the  physician,  instillation  of  a  V^fc 
solution  of  copper  sulfate  twice  daily  is  prescribed,  or 
it  may  be  used  in  the  form  of  a  1%  unguent.  Many 
physicians  prefer  Arlt's  use  of  copper  citrate,  usually 
as  unguent,  and  now  obtainable,  under  the  name  of 

69 


cuprocitrol,  in  tubes  of  1-5  grams,  from  the  Schiirer 
V.  Waldheimschen  Apotheke  in  Vienna.  With  a  glass 
rod  some  of  this  is  rubbed  once  daily  over  the  con- 
junctival surface.  It  is  less  irritant  than  other  ap- 
plications, and,  therefore,  safer  for  the  patient's  own 
use. 

Iodine  preparations  are  also  frequently  employed: 
Tinct.  iodi,  1.0,  glycerine,  15.0  as  collyrium ;  iodoform 
as  dusting-powder  or  in  unguent;  pure  iodine  (V2-l%) 
dissolved  in  glycerine  and  daubed  with  a  cotton  appli- 
cation over  the  everted  lids,  or,  a  caustic  pencil  may 
be  made  of  pure  iodic  acid  moistened  with  a  very  lit- 
tle water  until  plastic,  when  it  may  be  rolled  on  a  glass 
plate  into  pencil  form,  and  with  this,  cauterization 
may  be  performed  about  every  third  day.  The  pain 
is  intense,  but  soon  passes  off. 

Of  the  mechanical  procedures,  that  of  Keinig  is 
worthy  of  mention.  A  cotton  applicator  is  dipped 
into  a  1 :3000-5000  sublimate  solution,  and  the  cotton 
rubbed  vigorously  over  the  diseased  mucosa,  repeat- 
ing this  every  second  day  until  the  granules  have  dis- 
appeared. 

Operative  methods  have  the  advantage  of  greatly 
shortening  the  duration  of  the  disease,  a  desideratum 
in  epidemics.  But,  not  all  of  them  are  radical,  and  it 
is  always  advisable  to  follow  with  medicamental  treat- 
ment. With  Knapp's  roller- forceps,  built  on  the  plan 
of  a  clothes-wringer,  the  new-formed  trachoma  gran- 
ules may  be  expressed.  In  older,  deeper  infiltration, 
excision  of  the  fornices  or  of  the  tarsus  is  recom- 
mended. 

Trachoma  is  infectious,  and  preventive  measures 
are,  therefore,  to  be  prescribed-  The, most  dangerous 
carriers  of  the  contagium  are  dirty  wash-water  and 
towels. 


70 


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Conjunctivitis  Conorrhoica. 

Plate  XXIV.,  Figs.  34-35;  Plate  XXV.,  Figs.  36-37; 
Plate  XXVI.,  Fig.  38. 

Gonorrheal  disease  of  the  eye  is  chiefly  caused  by 
infection  from  the  exterior,  a  so-called  gonorrhea  by 
contact,  but,  we  have  other  types,  and  these  ophthal- 
mias may  be  classified  as: 

1.  Gonorrhea  by  contact: 

2.  Gonorrhea  by  metastasis  from  other  foci  in  the 
body. 

3.  Gonorrhea  where  metastasis  occurs  to  other 
parts  of  the  body,  especially  the  articulations,  nowa- 
days so  much  observed  and  investigated  by  the  sur- 
gical staff. 

Furthermore,  ophthalmic  affections  due  to  a  con- 
tact gonorrhea  are  often  divided  into  conjunctivitis 
gonorrhoica  neonati  and  hominis  adulti,  remembering, 
however,  that  there  is  no  qualitative  difference  be- 
twixt them.  Differentiation  is,  perhaps,  advisable, 
first,  because  of  origin,  secondly,  because  of  prognosis. 

Conjunctivitis  Gonorbhoica  Neonatorum. 

Ophthalmic  gonorrhea  following  birth  is  due  to  in- 
fection from  outside:  a  so-called  contact-gonorrhea. 

Neisser's  gonococci  enter  the  conjunctival  sac  dur- 
ing birth  and  often,  because  of  lack  of  cleanliness, 
after  birth.  After  brief  incubation,  varying,  with  the 
severity  of  infection,  from  a  few  hours  to  days  (com- 
monly after  2-3,  more  rarely,  after  4-5  days),  the  dis- 
ease breaks  loose.  The  lids  become  very  red  and 
swollen,  but  chemosis  is  rare.    Out  of  the  palpebral  fis- 

71 


sure  flows  a  secretion  at  first  turbid,  tlien  wholly 
purulent,  in  which,  lying  within  the  leucocytes  or  des- 
quamated epithelia,  are  found,  usually  in  pairs  and 
very  numerous,  the  gonococci,  not  staining  by  Gram's 
method.  After  some  weeks  the  thick,  creamy  pus  be- 
comes thinner,  and  at  last  ceases.  There  is  no  chronic 
conjunctivitis  gonorrhoica.  When  there  is  stasis  of 
the  pus  it  generally  corrodes  the  corneal  epithelium, 
which  then,  in  greater  or  less  measure,  disintegrates 
by  suppuration.  After  cession  of  the  inflammatory 
phenomena,  the  defect  is  hidden  beneath  an  opaque, 
whitish  cicatricial  tissue  (Plate  XXIV.,  Fig.  35).  In 
Fig.  35  in  the  upper  part  of  the  leucoma  is  a  small 
black  line,  an  anterior  synechia,  i.  e.  after  slight  per- 
foration of  the  cornea,  a  portion  of  the  iris  has  fallen 
forward  and  through  and  healed  fast  {vide  also  Fig. 
55  on  Plate  XXXVIII.,  leucoma  corneae  totale,  where 
the  destruction  of  the  cornea  was  due  to  variola,  ex- 
actly similar  in  appearance,  however,  to  that  caused 
by  conjunctivitis  gonorrhoica.)  If  the  cornea  be  to- 
tally destroyed  by  suppuration,  a  protective  partition 
is  formed  by  the  contraction  of  the  freely  exposed  iris 
across  the  pupillary  area  {vide  Plate  XXVI.,  Fig.  38), 
but  later,  intraocular  pressure  drives  this  curtain  for- 
ward and  we  have  a  total  staphyloma  corneae  {vide 
Plate  XIJ.,  Fig.  59). 

If  pus  find  its  way  into  the  interior  of  the  eye  there 
develops,  after  long  and  violent  inflammation,  a  grad- 
ual wasting  of  the  eyeball:  phthisis  bulbi  {vide  Plate 
XXV.,  Figs.  36-37). 

The  conjunctiva  is  markedly  red  and  swollen,  the 
papillae  spring  up  in  ridges  or  cockscomblike,  but 
there  is  never  formation  of  follicles  (as  in  conjuncti- 
vitis follicularis  or  in  trachoma),  nor,  after  the  dis- 
ease has  run  its  course,  do  we  find  cicatrices  in  the 
conjunctival  tissues. 

72 


Allns. 


Tab.  XXV. 


Fig.  36.    IMithisis  biillM  incipiens. 
Adhesion  form  of  Keratitis. 


'^m'' 


m 


Fig.  37. 
Phthisis  bulbi  quadrata. 


Comnanv    Mpw   Vnrlf 


Conjunctivitis  Gonorrhoica  Adultorum. 

One  might  suppose  that  the  eye  of  the  adult  was  but 
slightly  sensitive  to  the  gonococcal  virus,  and,  ap- 
parently, the  supposition  is  supported  by  statistics. 
In  the  large  cities  gonococcal  urethritis  is  extraordi- 
narily common,  but  the  percentage  of  ophthalmic  in- 
fection is  extremely  small,  perhaps  not  one  in  a  thou- 
sand individuals  with  urethritis  gonorrhoica  are  ocu- 
larly affected,  so  that  it  would  seem  true  that  the  eye 
has  very  slight  receptivity.  And  yet  the  cases  where 
the  eye  has  actually  become  infected  disprove  this. 
This  is  due  to  the  protection  afforded  the  eyeball,  mak- 
ing infection  difficult,  and  to  the  fact  that  the  gono- 
coccus  is  a  very  delicate  and  easily  destroyed  micro- 
organism. 

The  fresh  pus  must  be  brought  directly  into  the  eye, 
and  even  rubbing  with  the  infected  hand  does  not  al- 
ways infect  the  eye,  for  we  are  not  in  the  habit  of 
touching  conjunctival  tissues,  and  on  the  derm,  on  the 
skin  of  the  lid,  the  gonoeoccus  finds  no  point  of  attack. 
At  any  rate,  cases  where  the  virus  has  actually  got  in- 
to the  eye,  show  its  extreme  sensitivity  to  the  gono- 
eoccus. 

Conjunctivitis  gonorrhoica  in  adults  begins  vio- 
lently, much  more  so  than  in  the  newborn,  and  it  is 
important  to  know  this.  The  numerous  patients  with 
a  urethritis  gonorrhoica,  and  who  know  that  the  dis- 
ease is  transmissible  to  the  eye,  are  in  constant  anx- 
iety. If  it  happen  that  a  few  reddened  blood-vessels 
show  in  the  eye,  such  a  patient,  naturally,  is  greatly 
disturbed,  for  he  suspects  infection.  Such  individ- 
uals are  very  numerous  in  the  consultation  room.  And, 
when  we  see  a  conjunctivitis  with  marked  redness,  we 
can  usually  tell  from  its  period  of  duration  whether 
it  be  gonorrheic  or  not.  Gonorrheic  phenomena  do 
not  begin  with  redness  and  inflammation  of  the  con- 

73 


junctiva,  but  with  extremely  violent  lacrimation,  with 
hourly  aggravation  of  the  symptoms,  so  that  if  in  the 
morning  the  tears  were  clear,  at  midday  they  are  tur- 
bid, and  by  night  the  gonorrheal  picture,  a  wave  of 
pus  rolling  from  the  eye,  is  in  evidence.  When  we 
learn,  therefore,  that  the  symptoms  were  present  yes- 
terday or  the  day  before,  and  still  the  characteristic 
syndrome  of  a  gonorrheic  ophthalmia  is  not  before  us, 
we  may  usually  exclude  an  infection  and  pacify  the  pa- 
tient. When  such  syndrome  develops,  we  have  the 
marked  swelhng  and  edema  of  the  lids,  the  conjuncti- 
val chemosis,  and  the  specific  trickling  of  pus  from 
the  conjunctival  sac. 

In  adults,  the  cornea  is  much  more  apt  to  become 
affected  than  in  the  newborn,  so  that  even  the  most 
careful  treatment  is  not  always  able  to  hinder  an  un- 
fortunate termination. 

Conjunctivitis  Gonorrhoica  Metastatica. 

Besides  the  above-described  conjimctivitis  from  con- 
tact or  direct  infection,  we  have  a  conjunctivitis  gon- 
orrhoica metastatica,  somewhat  frequently  observed 
in  modern  times.  As  we  have  learned  to  recognize 
affection  of  the  joints  as,  not  rarely,  metastases  of 
gonorrhea,  so  the  ophthalmic  metastasis  has  been 
often  noted.    The  eye  is  peculiarly  apt  to  metastases. 

The  picture  of  ophthalmia  gonorrhoica  metastatica 
is  entirely  different  from  that  induced  by  contact  or 
direct  infection.  We  do  not  have  the  marked  suppura- 
tion ;  we  see  merely  a  conjunctivitis  with  some  circum- 
jacent edema,  and  often  an  iritis,  differing  little  from 
any  other  iritis.  In  the  great  majority  of  cases  also, 
there  are  no  gonococci  found  in  the  secretions.  Ap- 
parently, we  are  dealing  with  a  mixed  infection,  for 
we  know  that  the  plastic  inflammations  often  present 
in  precisely  this  form  of  iritis  are  not  due  to  gonococci. 

74 


In  short,  we  have  in  the  eye  a  number  of  symptoms 
found  also  in  gonorrheic  affections  of  the  joints. 

Finally,  there  are  cases  in  which  metastases  to  va- 
rious parts  of  the  body  have  proceeded  from  gonor- 
rheic affections  of  the  eye. 

The  prog'nosls  of  conjunctivitis  gonorrhoica  ne- 
onatorum is  favorable  when  the  treatment  is  correct; 
and  the  morbidity  is  almost  always  removed  without 
sequelae.  Without  treatment,  the  stagnating  pus 
erodes  the  cornea  and  more  or  less  destroys  it. 

In  adults,  the  result  is  not  so  certain,  for  even  most 
careful  treatment  does  not  always  prevent  corneal 
lesion. 

Prophylaxis  plays  a  chief  role.  Adults  with  gonor- 
rheic urethritis  or  a  gleet  are  to  be  warned  against 
touching  the  eyes,  and  the  hands  should  be  thoroughly 
cleansed  with  soap  and  water  after  each  contact  with 
the  pus.  With  the  newborn,  in  suspicious  cases, 
Crede's  method  of  instilling  a  drop  of  2%  solution  of 
silver  nitrate  into  each  eye  is  to  be  recommended,  or 
better,  this  too  strong  solution  may  be  reduced  to  Va 
per  cent.  Water  used  in  bathing  must  not  come  in 
contact  with  the  eyes. 

Therapy.  Where  but  one  eye  is  affected  in 
adults,  the  sound  eye  should  be  protected  by  a  watch- 
glass  or  a  piece  of  mica  held  in  place  peripherally  by 
adhesive  plaster.  In  treatment,  silver  nitrate  or  one 
of  its  substitutes,  protargol  or  argentamin,  is  best. 
The  classic  method  of  von  Grafe's  school  was  a  daily 
painting  over  with  a  3%  solution,  but  I  prefer  a  weaker 
(Vio-V"'^'')  silver  solution  with  which  the  eye  is  fre- 
quently irrigated  during  the  day  and  the  pus  washed 
out.  In  this  procedure,  all  friction  must  be  avoided, 
for  the  cornea  may  be  easily  injured  (particularly 
by  unskilled  hands),  with  serious  results.    A  piece  of 

75 


cotton  wet  with  the  solution,  or  a  vial  with  slit  cork 
should  be  held  at  a  distance  from  the  eye  and  the  so- 
lution allowed  to  driy)  in  betwixt  the  lids  which  are 
simultaneously  opened  and  closed,  thus  washing  out 
all  pus.  Where  the  lids  are  much  swollen  ice-com- 
presses may  be  applied  for  one  or  two  days  only. 

To  avoid  maceration  of  the  cornea  by  the  pus,  many 
authors  commend  one  application  daily  of  unguent. 
Recently,  the  5  or  10%  Lenicet  ointment  (Dr.  Eeiss, 
Berlin)  in  original  tubes,  or  Euvaseline  (Eeiss)  in 
original  packages  has  become  quite  famous. 

Against  leucoma  corneae,  all  therapy  is  ineffectual. 
If  partial  and  in  the  center  of  the  cornea,  one  may,  by 
excision  of  a  side  of  the  iris  (optic  iredectomy)  to- 
gether with  the  cicatricial  turbidity,  form  an  artificial 
pupil  {vide  Plate  XXIV.,  Fig.  35).  For  a  better  cos- 
metic effect,  the  white  spot  may  later  be  tinted  black 
with  Chinese  ink. 


76 


Fig.  38. 

Conjunctivitis  g-onorrhoica  adultorum. 

Prolapsus  iridis  totalis. 


Fig.  39. 
Pterygium  und  Pinguecula. 


ebinan  Cotnpany.  New  York. 


Pinguecula,  Pterygium. 

Plate  XXVI.,  Fig.  39. 

Pinguecula  (Lidspaltenfieck)  belongs  with  the  se- 
nile degenerations.  In  the  region  of  the  triangular 
portions  of  the  conjunctiva  bulbi  lying  on  each  side 
of  the  cornea  when  the  eye  is  open,  there  develop  in 
time  thickenings  of  the  conjunctival  tissues  which 
gradually  become  straw-colored  elevations.  Their 
evolution  is  favored  by  weather  disturbances,  living 
in  an  atmosphere  of  smoke  and  dust,  by  a  hot,  sun- 
struck  climate,  etc. 

As  the  name  denotes,  it  was  formerly  believed  that 
the  Pinguecula  was  composed  of  fat  (pingue,  fat),  but 
it  is  actually  a  hypertrophy  of  elastic  tissue  associated 
with  granular  pigment. 

Progrnosis.  The  growth  has  no  significance,  and 
merely  disfigures.  Sometimes  its  appearance  greatly 
terrifies  the  patient  or  his  family,  and  hence  it  is  im- 
portant to  recognize  the  nature  of  the  phenomenon. 
It  needs  no  therapeutic  intervention. 

From  Pinguecula,  a  pterygium  may  develop. 

Pterygium  is  a  triangular  fold  of  mucous  mem- 
brane, growing  horizontally  from  either  side  of  the 
conjunctiva  bulbi  toward  and  over  the  cornea.  The 
blunt  apex  of  the  triangle  lies  in  the  transparent  cor 
nea  to  which  it  is  firmly  and  immovably  attached. 

In  a  pterygiimi,  we  differentiate  the  head  or  blunt 
apex,  then  the  thin  neck,  and,  finally,  the  broad  body 
lying  upon  the  sclera. 

77 


It  grows  gradually  and  without  inflammation  across 
the  cornea  and  is  rich  in  blood-vessels.  Usually,  it  is 
progressive  and  in  the  course  of  years  may  reach  and 
pass  beyond  the  center  of  the  cornea.  It  is  found  in 
elderly  individuals  and  is  more  common  in  hot  cli- 
mates than  with  us.  Pterygium  evolves  from  a  Pin- 
guecula. The  latter  begins  to  grow  suddenly  toward 
the  cornea,  and  pulls  after  it  a  flap  of  conjunctival 
tissue. 

Prog-nosis.  Pterygium  causes  visual  disturb- 
ances as  soon  as  it  enters  the  corneal  field  and  when 
it  covers  the  pupil  entirely,  the  eye  becomes  practi- 
cally blind,  though  able  to  cognize  light.  As,  com- 
monly, it  is  progressive,  the  prognosis  is  unfavorable 
unless  the  growth  be  removed  by  operation. 

Therapy  comprises  the  ablation  of  the  growth 
and  suturing  of  the  conjunctival  wound.  This  should 
be  done  as  early  as  possible,  for  the  corneal  area  af- 
fected by  the  ablation  will  never  regain  its  smooth 
surface. 

Hence,  after  the  removal  of  far-advanced  ptery- 
gium, there  always  remain  disturbances  of  vision. 


78 


ff,  Atlas. 


Till)    XXVU. 


Fig.  40. 
Conjunctivitis  diphtherica. 


oiiipaiiy,  Xtw  York. 


Conjunctivitis  Diphtheritica. 

Plate  XXVII.,  Fig.  40. 

Infection  of  the  conjunctival  tissue  with  the  Klebs- 
Loffler  bacillus  we  term  conjunctivitis  diphtheritica. 

Von  Grafe  was  acquainted  only  with  the  grave, 
deeply  penetrating,  necrosing  form  of  ophthalmic 
diphtheria,  which  usually  begins  with  corneal  impli- 
cation. Later,  a  mild,  superficial  form,  accurately 
differentiated,  however,  from  the  true  form,  was  de- 
scribed as  croup  of  the  conjunctiva.  These  nosologic 
viewpoints  were  altered  only  by  the  discovery  of  the 
active  cause,  for  in  1886  the  diphtheria  bacillus  was 
first  demonstrated  by  Babes  in  conjunctival  diphtheria 
(Prager  med.  Wochenschrift,  1886,  Nr.  8). 

Still  later,  the  bacillus  was  also  found  in  the  mild, 
superficial  form.  To-day  it  is  certain  that  both  forms 
should  be  classified  imder  the  head  of  conjunctivitis 
diphtheritica.  We  must,  therefore,  in  every  conjuncti- 
vitis with  superficial,  pseudo-membrane  and  of  benign 
course,  harbor  the  suspicion  that  we  are  dealing  with 
diphtheria.  I  say,  "harbor  the  suspicion,"  for  we 
cannot  be  clinically  sure  without  a  bacteriologic  ex- 
amination, for  gonococci  and,  even  more  frequently, 
streptococci  may  form  membranes.  And,  conversely, 
virulent  diphtheria  bacilli  may  develop  merely  a  sim- 
ple conjunctival  catarrh  (simple  catarrhal  form)  with- 
out the  formation  of  a  membrane.  We  thus  see  the 
importance  of  bacteriologic  examination. 

Why  the  virulent  bacilli  develop  now  a  benign,  su- 
perficial morbidity,  and  again,  one  deeply  penetrating 
and  necrotogenic,  we  do  not  know. 

79 


Id  most  ophthalmic  diphtherias,  the  diphtheria  ba- 
cilli are  not  found  in  pure  culture,  but  mixed  with 
staphylo-  and  streptococci,  and  finally,  with  avirulent 
xerosis  bacilli  (pseudo-diphtheria  bacilli).  It  ap- 
pears, however,  that  these  mixed  infections  have  no 
influence  upon  the  course  of  the  disease. 

Diag'nosis  in  the  superficial  form  is  not  easy,  for 
staphylo-  and  streptococci  as  well  as  slight  cauteriza- 
tions occasionally  develop  membranes.  Demonstra- 
tion of  Loffler's  bacillus  renders  the  diagnosis  certain. 

Prognosis  is  always  dubious.  Many  cases 
recover  unharmed,  but  even  the  mildest  type  may  sud- 
denly become  malignant,  destroying  the  cornea,  de- 
veloping gangrene  of  the  lids,  or,  by  general  infection, 
threatening  life. 

Therapy.  Immediate  isolation.  Injection  of 
Behring's  serum  beneath  the  skin  of  the  abdomen  or 
the  eyelid.  Frequent  cleansing  of  the  conjunctival  sac 
with  sublimate  1 :5000  or  potass,  perm.  1 :5000. 

Membranes  and  coatings  are  to  be  removed  only 
when  this  can  be  accomplished  by  a  gentle  brushing, 
and  forcible  divulsion  of  deep-lying  membranes  is  to 
be  avoided  most  carefully. 


80 


Tab.  XXVlll. 


Fig.  41. 
Blepharitis  and  Conjunctivitis  eczematosa. 


m  Coiiipany,  New  York 


Tab.  XXIX. 


Fig.  42. 

Conjunctivitis  and  Keratitis  phlyctaenuiosa. 

Eczema  faciei. 


nn  Company,  NcwYork. 


Conjunctivitis  and  Keratitis 
Phlyctaenulosa. 

Plate  XXVIII.,  Fig.  41 ;  Plate  XXIX.,  Fig.  42 ;  Plate 
XXXII.,  Fig.  47. 

The  above  disease  boasts  a  numerous  array  of  syn- 
onyms. Besides  conjunctivitis  phlyctaenulosa  we  have 
C.  eczematosa,  C.  scrofulosa,  C.  lymphatica  and  kera- 
titis superficialis. 

The  disease  is  characterized  by  an  eruption  of 
phlyctenules,  i.  e.  eczema  pustules  on  the  surface. 
These  are  cone-like  elevations  of  the  epithelium  about 
the  size  of  a  millet  seed,  and  their  favorite  location  is 
the  corneo-scleral  boundary  of  the  margin  or  limbus. 
where  they  are  apt  to  develop  in  rows  {vide  Plate 
XXIX.,  Fig.  42).  Soon  a  number  of  superficial  blood- 
vessels are  seen  extending  toward  the  growth,  and 
these  develop  likewise  in  the  superficies  of  the  cornea 
after  the  appearance  of  phlyctenules  in  that  region 
(Plate  XXXII.,  Fig.  47),  in  which  case  the  lesion  is 
called :  keratitis  fasicularis. 

After  a  somewhat  brief  period,  the  phlyctenules 
rupture,  i.  e.  the  apex  of  the  cone  falls  off,  and  we  have 
left  small  gray  ulcers  which  heal  rapidly  and  become 
covered  with  epithelium.  The  disease  may  pass 
through  these  phases  within  3-4  days.  Commonly, 
there  is  also  present  an  eczema  upon  head  or  face.  As 
a  rule,  the  basic  factor  in  the  disease  is  scrofulosis. 

Progri^OSis.  The  individual  phlyctenule  may  run 
its  course  rapidly  and  safely,  but  relapses  invariably 

81 


occur  as  long  as  the  primary  disease  remains  untreat- 
ed. If  the  phlyctenules  persist,  they  cause  corneal  in- 
filtration which  heals  cicatricially,  the  scar  being 
termed  a  macula  comeae. 

Therapy  must  first  take  into  consideration  the 
underlying  scrofulosis.  Diet,  iron,  cold  baths,  -brine 
treatment,  living  in  the  open  air  and  all  the  hygienic 
measures  suited  to  scrofulous  children.  Since  obstipa- 
tion often  exists,  the  treatment  should  begin  in  children 
with  the  internal  administration  of  calomel,  after 
which  the  eczema  of  the  head,  nose  or  ears,  or  on  the 
face  should  be  handled.  Otherwise,  relapses  occur 
{vide  Therapy,  page  40).  Once  daily,  application  of 
unguentum  flavum  (hydrarg.  oxid  via  humid,  parat 
0.1 :  vaselin.  flav.  10.0)  should  be  made  to  the  area  af- 
fected, spreading  it  over  the  surface  by  movements  of 
the  lids.  In  the  later  stages,  the  cicatricial  cloudiness 
of  the  tissues  may  be  cleared  up  by  insufflation  of  the 
finest  calomel  powder. 


82 


recff,  Atlas. 


Tab    XXX. 


Fig.  4;').   Conjunctivitis  vernalis. 
Ciianges  in  tiie  Conjunctiva. 


Fig.  44.   Conjunctivitis  vernalis.    Changes  in  the  Limbus. 


ri  Company,   New  York. 


Conjunctivitis  Vernalis. 

Plate  XXX.,  Fig.  43  and  44. 

Conjunctivitis  vernalis  or  spring  catarrh  is  a  some- 
what rare  disease,  affecting  chiefly  the  male  sex  in 
youth.  The  disease  begins  in  spring-time,  usually  in 
both  eyes,  and  after  some  months  disappears  or  be- 
comes milder.  It  continues  thus,  with  relapses,  for  3 
or  4,  even  10  and  more  years. 

Those  afflicted  are  greatly  annoyed  by  itching  and 
burning  in  the  eyes. 

There  are  two  very  characteristic  anatomic  changes 
in  conjunctivitis  vernalis;  the  first  above  the  tarsus 
of  the  upper  lid,  the  second  at  the  limbus  corneae.  At- 
tacks may  occur  where  only  the  one  or  the  other 
change  is  present,  and  many  authors  therefore  differ- 
entiate a  palpebral  form  and  a  bulbar  form.  Usually, 
however,  both  conditions  develop,  and  these  are  the 
characteristic  cases.  Others  do  not  exhibit  these  typ- 
ical anatomic  insignia,  but  we  find  the  conjunctiva  in- 
jected and  with  an  equally  distributed  thickening.  In 
such  cases  diagnosis  may  be  arrived  at  only  by  the 
history. 

In  palpebral  tissue-changes,  the  conjunctiva  tarsi 
exhibits  broad  but  flat  papills  which,  when  numerous, 
give  this  part  of  the  lid  the  appearance  of  being  set 
with  small  cobblestones.  These  papill?e  often  have  a 
diameter  of  several  millimeters,  an  elevation  some- 
what less.  They  have  a  rounded  periphery,  unless 
pressed  flat  and  angular  by  neighboring  growths;  the 
superior  surface  is  flattened  from  above,  or  even  some- 

83 


what  concave.  The  papillae  feel  hard  to  the  touch. 
Homer  fittingly  compared  the  growths  to  colonies  of 
mould.  Sometimes  they  are  of  the  density  of  car- 
tilage. The  conjunctiva  above  the  excrescence  and  ad- 
jacent to  it,  has  a  peculiar,  blue-white,  milky  shim- 
mer, so  that  its  surface  appears  pallid  rather  than  in- 
flamed. The  "mushrooms"  are  soon  present  in  large 
numbers,  sometimes  crowded  together,  sometimes  iso- 
lated, thus  giving  the  impression  of  having  been 
rubbed  off,  their  primary  seat  distinguished  only  by 
the  delicate  furrows  left. 

The  conjunctiva  of  the  lower  lid  is,  as  a  rule,  only 
thickened,  without  furrows,  and  of  the  same  pallid, 
milky  appearance,  whilst  tissue  alterations  of  the  for- 
nices,  violent  inflammation  and  follicles  are  lacking. 

The  changes  in  the  conjunctiva  bulbi  are  much  more 
conspicuous  and  earlier  observed.  Correspondent  to 
the  palpebral  fissure,  we  note  some  of  the  peripheral 
blood-vessels  approaching  the  limbus  corneae,  and  in 
the  limbus  itself  are  found  hard,  knobby  elevations  of 
a  bluish-white  tint,  and  found  mostly  situate  on  the 
internal  and  external  margin  of  the  cornea.  They 
may  also  be  seen  as  a  narrow  band  of  thickened,  gel- 
atinous consistency  encompassing  the  entire  limbus. 
Sometimes  the  elevations  are  flattened,  and  may  per- 
sist for  years;  in  other  cases,  nodular  tumors  are  de- 
veloped from  them. 

Anatomically,  we  have  not  a  syndrome  of  conjunc- 
tival inflammation,  but  a  purely  hypertrophic  process 
in  the  areas  affected.  The  epithelium,  in  particulate, 
is  much  thickened,  giving  to  the  conjunctiva  its  macro- 
scopic, bluish-milky  luster.  Superficially,  the  eleva- 
tions are  usually  three  times  thicker  than  the  norm,  so 
that  often  there  are  as  many  as  30  cell  strata  superim- 
posed, one  upon  the  other.  The  epithelium  also  sends 
cell-cords  into  the  deeper  tissue,  cells  in  cords  and 

84 


nests  with  the  formation  of  the  most  varied  figures, 
the  syndrome  reminding  one  of  carcinoma,  but  not 
penetrating  so  deeply  into  the  tissues. 

Diag-nosls.  The  disease  may  be  sometimes  con- 
fused with  trachoma,  but  the  compactness  of  the  ele- 
vations, their  pave-stone  appearance,  the  milky  shim- 
mer permit  its  recognition.  The  diagnosis  becomes 
certain  if  we  also  have  present  the  characteristic 
thickening  of  limbus  tissue. 

The  progrnosls  is  favorable  in  that  the  disease 
finishes  its  course  without  injury  to  the  eye,  but  un- 
favorable since  no  remedy  is  capable  of  abbreviating 
the  process. 

Therapy.  Strong  cauterization  of  the  affected 
areas  is  to  be  shunned  for  it  only  aggravates  the 
condition.  The  use  of  a  mildly  astringent  coliyrium, 
as  in  conjunctivitis  catarrhalis,  is  indicated  here.  A 
xeroform  or  anesthesin  dusting-powder  or  the  instil- 
lation of  acid.  acet.  dil.  1 :1000  several  times  daily  is 
commended  for  the  relief  of  itching.  For  the  prolifer- 
ations in  the  limbus,  massage  with  2  or  5%  yellow  pre- 
cipitate unguent  may  be  employed. 

When  the  papillary  proliferations  become  very 
large,  they  may  be  removed  with  scissors  or  the  gal- 
vanic platinum  loop. 


85 


Tumors  of  the  Corneo-Scleral 

Margin.    Xeroderma 

Pigmentosum. 

Plate  XXXI.,  Fig.  45. 

Epibulbar  tumors  usually  develop  in  individuals  of 
middle  or  advanced  age,  and  begin  almost  invariably 
in  the  corneoscleral  margin,  very  seldom  in  the  cen- 
tral area  of  the  conjunctiva  bulbi.  According  to  Vir- 
chow,  there  occasionally  appear  deeply  pigmented  con- 
nective tissue  cells  in  the  corneal  margin,  also  small 
black  flecks  (melanomata)  composed  of  such  cells,  and 
these  are  genetic  in  the  formation  of  new  growths. 
Often  no  reason  for  their  development  can  be  discov- 
ered; in  other  instances  they  follow  some  slight  in- 
jury or  evolve  from  scar-tissue  in  the  margin  of  the 
cornea.  Long-continued  irritation,  such  as  working  in 
a  dust-laden  atmosphere,  is  presumably  favorable  to 
their  genesis.  In  most  cases,  a  pigment  fleck  in  the 
limbus  conjunctivae  is  first  seen,  which  slowly  attains  a 
fungoid  growth.  Sarcomata  usually  have  a  smaller 
stem  or  trunk,  extend  more  superficially,  are  of  soft 
consistency,  have  many  blood-vessels,  and  look  like 
more  or  less  pigmented,  reddish  nodules.  Carcino- 
mata  develop  a  wider  growth.  At  first  glance,  they 
often  appear  as  if  firmly  and  extensively  attached  to 
the  corneal  surface,  but  a  careful  examination  with  a 
blunt  sound  demonstrates  that  it  is  a  mere  superimpo- 
sition  and  that,  generally,  there  is  no  union  of  tissues. 

86 


f,  Atlas. 


Tab.  XXXI. 


Fig.  45. 
Xeroderma  pigmentosum.     Tumor  epilnilbaris. 


Cniiipaiiy,    New  York 


Progressing  backwards,  they  unite  with  the  conjunc- 
tiva and  with  it  are  movable  over  the  eyeball,  a  sign 
tLat  the  neoplasm  has  not  penetrated  deeply. 

If  the  tumor  be  not  removed,  its  periphery  slowly 
extends,  attacks  conjunctiva  and  cornea,  and  in  time 
forms  an  enormous  neoplasm. 

If  patients  come,  as  is  commonly  the  case,  with  more 
or  less  pigmented,  fungoid  tumors  of  the  size  of  a  len- 
til or  pea,  the  thorough  removal  of  the  neoplastic  tis- 
sue suffices.  The  nodule  is  severed  with  scalpel  or 
scissors,  and  its  base  cleaned  up  with  the  sharp 
curette,  followed  by  cauterization  with  the  Paquelin. 
A  soft  tumor  is  generally  rooted  in  the  superficial  lay- 
ers of  the  tissue.  One  should  not  fail  to  warn  the  pa- 
tient of  the  malignancy  of  the  growth  and  emphasize 
the  necessity  of  his  appearing  from  time  to  time  in 
the  consultation  room. 

In  a  number  of  cases,  the  removal  of  the  timaor  leads 
to  a  cure,  yet  relapses  occur  in  a  majority  of  cases, 
though  these  exhibit  an  extraordinarily  slow  growth. 
With  very  large  and  extensive  tumors,  the  exenteratio 
orbitae  or  enucleation  of  the  eye  is,  conditionally,  com- 
mended, though  in  such  cases  there  has  occurred  me- 
tastasis to  the  inner  organs,  and  the  patient  dies  from 
exhaustion  or  tumor  formation  elsewhere. 

Xeroderma. 

By  xeroderma  pigmentosum  we  mean  a  peculiar 
morbid  syndrome  first  described  by  Kaposi  (1870)  in 
his  textbook  on  Diseases  of  the  Skin.  Altogether,  up 
to  the  present  day  there  have  been  reported  a  little 
over  100  cases,  which  is  not  many  when  we  consider 
that  the  growths  are  sometimes  multiple,  most  apt  to 
be  among  members  of  the  same  family,  and  further 
that,  with  the  great  interest  aroused  by  a  case,  it  is 
unlikely  that  a  single  one  has  escaped  publication. 

87 


Some  cases  have  also  been  reported  several  times  by 
different  authors. 

The  disease  is  accepted  by  most  authors  as  due  to  a 
congenital  pre-disposition,  to  which  corroboration  is 
given  by  the  fact  that  the  morbidity  in  almost  all  of 
the  reported  cases  was  found  in  children  of  the  same 
family,  e.  g.  in  one  instance  in  seven  brothers.  And, 
in  single  eases  it  aifected  only  children  of  the  same 
sex,  in  other  cases  both  sexes  were  involved,  facts  sim- 
ilar to  those  observed  in  other  inherited  diseases.  In 
our  own  cases,  there  were  two  brothers  affected,  in  the 
elder  of  which  the  disease  was  far  advanced.  But, 
neither  in  our  cases  nor  in  those  of  others  were  there 
any  morbid  conditions  in  the  parents  demonstrable  as 
having  any  definite  relationship  with  the  disease  af- 
fecting the  children.  Neither  consanguinity,  constitu- 
tional or  dermal  conditions,  nor  even  weakliness  were 
present.  The  children  were  bom  with  a  normal  derm, 
but  even  in  the  first  period  of  extrauterine  life,  the  ini- 
tial phenomena  appeared.  Under  the  action  of  the 
sun's  rays  during  the  first,  or,  at  most,  the  second 
year  of  life,  there  developed  on  the  exposed  portions 
of  the  body,  face,  neck,  hands  and  forearms,  on  the 
feet  and  legs  of  children  going  bare-foot,  circum- 
scribed, red  spots  which  disappeared  in  a  short  time 
with  slight  desquamation,  but  invariably  reappeared 
after  further  exposure  to  the  sun.  Lukasiewicz  him- 
self was  able  to  observe  a  diffuse  redness  of  the  skin 
as  the  initial  stage  of  the  disease.  As  often  as  his 
little  patient  remained  but  a  short  time  in  the  open  air 
on  sunny  days,  there  appeared  after  a  few  hours  a 
diffuse  reddening  and  swelling  of  the  diseased  areas 
of  skin.  The  rubescence  paled  under  pressure  of  the 
fingers,  which  caused  pain.  There  was  no  elevation  of 
temperature  but  a  well-marked  state  of  depression  in 
the  patient.     For  a  few  days  these  symptoms  were 

88 


aggravated,  then  diminishing  with  slight  degeneration. 
There  was  frequent  repetition  of  the  above  syndrome, 
particularly  in  spring  and  summer,  whilst  in  winter, 
when  the  patient  remained  indoors,  the  eiythema  never 
made  its  appearance. 

In  typical  cases,  permanent  alterations  soon  occur. 
During  this  period,  which  may  be  termed  the  second 
stadium,  pigmentation  sets  in.  On  the  exposed  parts 
of  the  body,  numerous  freckle-like  spots  develop, 
whilst  elsewhere  pigmentation  diminishes,  so  that 
there  are  areas  free  of  pigment  and  perfectly  white. 
Altogether,  the  pigmentation  increases  so  that  the  af- 
fected areas,  compared  to  the  normal  skin,  appear 
brown  and  even  black. 

Further  along  in  the  disease,  there  is  much  vascu- 
lar dilatation,  usually  in  the  form  of  small,  flat  but 
numerous  telangiectases,  more  rarely  angiomatoid  tu- 
mors. 

The  skin,  in  general,  becomes  atrophic,  smooth,  and 
the  normal  furrows  and  folds  disappear.  If  a  piece  of 
such  skin  be  examined,  there  is  found  a  degenerative 
process  analogous  to  that  of  senility  in  the  sense  of 
an  atrophy,  a  thinning  and  flattening  of  the  papillsB 
and  their  epidenn. 

With  this,  we  find,  microscopically,  a  typical  pene- 
tration of  the  rete  cells  into  the  chronically  altered 
cutis,  hyperplasia  of  the  sebaceous  glands  and  ectasia 
of  individual  blood-vessels  (Lukasiewicz).  These  fur- 
nish the  needful  conditions  for  the  development  of  the 
last  stage  of  the  disease :  multiple  carcinoma.  Here  and 
there,  correspondent  usually  to  folds  of  the  skin,  ele- 
vations appear  which  develop  into  wart-like  processes 
so  that  often  the  brown-black  areas  of  the  affected 
parts  are  wholly  covered  with  them.  From  a  greater 
or  less  number  of  such  nodules,  there  then  develop 
genuine    epithelial    carcinomata,   which,    though   like 

89 


other  epithelial  cancers,  are  steadily  progressive,  by 
disintegration  lead  to  enormous  ulceration,  or  by  rea- 
son of  the  gradually  increasing  cachexia  cause  death, 
though  apparently  without  metastasis  to  internal 
organs. 


90 


iff.  Atlas. 


Tab.  XX> 


o 
tr. 
c 
o 


Eg 


Rebin;in  Company,  New  York. 


Lipoma  Subconjunctivaie 
Congenitum. 

PiATE  XXXII.,  Fig.  46. 

This  lipoma  is  a  not  very  infrequent  congenital  tu- 
mor, located  in  the  external  canthus  beneath  the  con- 
junctiva bulbi  and  between  the  insertions  of  musculus 
rect.,  externus  and  the  musculus  rect.  superior.  With 
the  conjunctiva  (somewhat  thickened  over  the  tumor), 
it  is  easily  movable  upon  the  subjacent  tissue.  The  lipo- 
ma, commonly  the  size  of  a  lentil  or  pea,  has  a  yellow- 
ish shimmer  through  the  overlying  conjunctiva.  To- 
ward the  corneal  side  the  tumor  appears  shorn  off, 
cliff-like,  whilst  on  the  temporal  side  it  gradually  flat- 
tens and  passes  into  the  fatty  orbital  tissue.  If  the 
lipoma  be  small,  it  may  not  be  noticed  at  first  glance, 
and  is  first  seen  by  a  side-glance  toward  the  nose. 
Microscopically,  it  is  composed  essentially  of  hyper- 
plastic fatty  tissue. 

Diagnosis  of  this  lipoma  is  infallible,  for  no  other 
tumors  are  found  in  this  region. 

The  prog-nosis  is  absolutely  favorable.  The  tu- 
mor may  begin  its  growth  at  puberty,  but  is  always 
comparatively  benign,  though  it  may  push  out  through 
the  palpebral  fissure,  and  thus  hinder  exact  approx- 
imation. 

Tberapy.  If  small,  the  tumor  may  be  left  to  it- 
self. It  is  better,  however,  to  remove  it,  as  it  may 
cause  disfigurement.  The  extirpation  of  the  fatty 
mass  after  splitting  the  conjunctiva  is  simple  and 
need  not  be  absolutely  radical. 


91 


Keratitis  Parenchymatosa 
Sive  Interstitialis. 

Plate  XXXHI.,  Pig.  48;  Plate  XXXIV.,  Pig.  49-50; 
Plate  XXXV.,  Pig.  51 ;  Plate  XXXVI.,  Pig.  52. 

(Synonyms:  Keratitis  interstitialis,  profunda,  dif- 
fusa, syphilitica,  uveitis  anterior.)  Parenchymatous 
inflammation  of  the  cornea  is  a  distinctly  characterized 
disease,  usually  beginning  and  running  its  course  in  a 
very  typical  manner.  Exact  knowledge  of  it  is  the 
more  important  because  it  must  always  be  considered 
as  a  constitutional  malady.  Its  appearance,  therefore, 
renders  it  the  duty  of  the  physician  to  make  an  accu- 
rate and  thorough  examination  of  the  patient,  for,  with 
the  commencing  keratitis  parenchymatosa  as  the  first 
symptom,  there  will  almost  invariably  be  found  other 
symptoms  pointing  to  a  hitherto  latent  constitutional 
disease,  in  most  cases  syphilis  hereditaria  (keratitis 
syphilitica  or  keratitis  ex  lue  congenita). 

As  for  the  name  given  the  disease,  keratitis  paren- 
chymatosa is  most- used,  though  not  the  best,  for,  of 
course,  all  diseases  of  the  cornea  implicate  more  or 
less  its  parenchyma.  Keratitis  syphilitica  correlates 
it  with  the  etiology,  but  is  not  suited  to  all  cases,  and, 
moreover,  is  not  characteristic  of  direct  lues,  but  only 
of  inherited  syphilis.  Keratitis  profunda  denotes 
correctly  that  the  morbid  process  is  carried  on  in  the 
deeper  layers,  but  corneal  ulcers  also  penetrate  the 
deepest  strata.  Hence,  keratitis  interstitialis  or  kera- 
titis diffusa  would  serve  best  for  the  equable,  diffuse 

92 


ecff,  Atlas. 


Tab.  XXXllI. 


Fig.  48. 
Keratitis  interstitiaiis. 


in  Company,     New  York. 


progress  of  the  disease  over  the  entire  cornea,  which 
is  perfectly  characteristic.  The  recently  justified 
term,  uveitis  anterior,  we  shall  discuss  later. 

The  disease  usually  begins  in  one  eye,  though  also 
in  both,  with  a  delicate  pericorneal  injection,  soon  aug- 
menting in  intensity  and  immediately  pointing  to  a 
more  violent  and  deep  ophthalmic  affection.  Soon 
there  is  noticed  in  some  part  of  the  cornea  a  turbid, 
lusterless  area,  generally  triangular  in  form,  begin- 
ning at  the  periphery  and  thence  extending  to  the  cen- 
ter of  the  cornea. 

The  turbidity,  observed  with  the  naked  eye,  seems 
uniformly  gray,  but  with  a  lens  or  even  by  focal  il- 
lumination it  is  seen  to  be  composed  of  a  number  of 
small,  whitish  flecks.  To  this  turbid  area  first  discov- 
ered, others  are  added  which  become  confluent,  and 
finally  implicate  the  entire  oornea  in  the  same  manner. 
The  cornea  looks  like  a  piece  of  glass  which  has  been 
breathed  upon  or  rubbed  over  with  fat,  and  the  deeper- 
lying  parts  but  shimmer  through  it  or  else  are  barely 
discernible.  In  differentiation  from  superficial  kera- 
titis it  is  important  to  note  that  the  corneal  surface 
exhibits  no  gross  changes,  no  nodules,  vesicles,  etc., 
nor  indentations,  epithelial  defects  or  ulcers.  But 
with  the  lens  we  see  that  the  epithelium  is  raised  up  in 
many  minute  elevations  equally  distributed  over  the 
whole  corneal  surface,  giving  it  a  finely  granular  ap- 
pearance. This  is  beautifully  seen  with  the  kerato- 
scope  of  Placido;  nowhere  are  the  concentric  rings, 
mirrored  against  the  cornea,  broken,  but  the  circum- 
ferences exhibit  rounded  margins  or  edges. 

With  the  development  of  corneal  turbidity,  there 
begins  an  extensive  vascular  proliferation  in  its  tissue. 
The  new-formed  vessels  extending  from  the  marginal 
network  stop  at  the  limbus  or  pass  just  into  it,  form- 
ing a  reddish  plaque  around  the  cornea.    The  deeper- 

93 


lying  episcleral  vessels,  on  the  contrary,  frequently 
push  into  the  deep  corneal  strata,  their  advance  always 
being  a  little  behind  that  of  the  corneal  opacity,  with 
whose  progress,  however,  they  advance  further.  In 
mild  cases,  few  blood  vessels  are  found  in  the  cornea, 
and  these  are  often  imbedded  in  the  opacity  and  diffi- 
cultly seen.  When  the  malady  is  more  violent,  the 
vascular  growth  is  steadily  forwards  until  the  entire 
cornea  is  finally  of  a  dirty,  raw-meat  hue.  These 
blood-vessels  have  a  very  characteristic  appearance. 
Whilst  in  pannus  trachomatosus  they  usually  twist 
and  interlace,  here  they  pursue  a  direct  course  in  par- 
allel; even  after  dividing,  the  branches  run  directly 
and  in  parallel  toward  the  center,  thus  resembling  the 
hairs  of  a  brush. 

Simultaneously  with  the  parenchymatous  keratitis, 
there  develops  a  more  or  less  noticeable  involvement 
of  the  uveal  tract,  varying  from  a  simple  hyperemia 
of  the  iris  to  an  intense  irido-chorioiditis.  The  fre- 
quent, almost  invariable  iritis  is  betrayed  by  the  peri- 
corneal injection,  the  swollen,  discolored  appearance 
of  the  iris,  and  the  tendency  of  the  pupils  to  contract. 
If,  in  this  stadium,  there  be  no  artificial  dilatation  of 
the  iridic  opening,  intense  cases  will  develop  a  perma- 
nent posterior  synechia  and  even  occlusion  of  the 
pupil.  Even  after  the  frequent  instillation  of  atropin, 
the  pupil  often  exhibits  the  tendency  to  contract.  If 
one  has  the  opportunity  to  use  the  ophthalmoscope  at 
the  beginning  of  the  disease  whilst  the  cornea  is  yet 
transparent,  he  will  see  in  the  anterior  portions  of 
the  fundus  oculi,  large,  black  spots,  indicating  a  cho- 
rioiditis or  uveitis  anterior.  This  chorioiditis  would 
probably  be  considered  one  of  the  most  frequent  phe- 
nomena accompanying  keratitis  parenchymatosa,  did 
not  the  opacity  of  the  cornea  rapidly  interfere  with 
ophthalmoscopic  examination. 

94 


f(.  Atlas. 


Fig.  49.     Hutchinson's  Teetii. 


Fig.  50. 
Rhachitic  Teeth. 


NTn,,,      V^^I. 


In  some  cases,  alterations  of  intraocular  pressure 
occur,  it  being  occasionally  lowered.  Increase  in  pres- 
sure is  rare,  and  develops  only  after  long  continuance 
of  the  disease. 

Vision  in  this  affection  is  always  considerably  les- 
sened. Generally,  the  coarsest  print  cannot  be  read 
and  only  motions  of  the  hand  are  cognized.  Both 
the  testing  of  vision  and  the  examination  of  the  eye 
are  hindered  by  the  often  violent  photophobia  and  the 
accompanying  profuse  lacrimation  of  the  affected 
eyes.  In  the  initial  stage  of  the  disease,  there  are 
often  strikingly  few  subjective  symptoms  and  no  pain, 
but  later  there  is  suflScient  pain,  though  if  the  disease 
be  properly  handled,  the  pains  are  not  intense.  Pho- 
tophobia, as  a  rule,  troubles  the  patient  most. 

To  the  disease  syndrome,  with  its  complications, 
above  described,  may  be  added,  according  to  the  in- 
tensity of  the  inflammation,  a  number  of  variations, 
but  the  disease  commonly  presents  enough  of  the  char- 
acteristic symptoms  to  make  diagnosis  easy.  As  con- 
trasted with  a  superficial  keratitis,  one  should  note 
that  here  we  have  no  ulceration  and  almost  never  any 
gross  elevations  of  the  corneal  surface,  so  that  in  kera- 
toscopic  observation,  though  the  contours  of  the  circles 
be  not  sharply  defined,  they  are  still  concentric  and 
circular.  Furthermore,  the  general  habitus  of  the 
patient  aids  in  the  determination  of  an  extremely  im- 
portant differential  diagnosis.  Superficial  keratitis 
is,  usually,  a  symptom  of  the  scrofulous  constitu- 
tion with  its  nasal  troubles,  eczemas,  glandular  affec- 
tions; parenchymatous  keratitis  is  commonly  a  symp- 
tom of  hereditary  lues. 

Keratitis  parenchymatosa  almost  always  attacks 
both  eyes,  not  always  synchronously  but  with  a  short 
interval  of  time  between ;  more  rarely  there  are  inter- 
vals of  weeks  and  months.     The  disease  usually  de- 

95 


velops  between  the  6th  and  18th  years  of  life.  Ex- 
ceptionally, individuals  over  20  years  of  age  have  been 
attacked,  and  these  cases,  as  a  rule,  run  an  atypic  and 
milder  course,  and  with  them  in  rare  instances,  one 
eye  alone  may  be  affected.  The  disease  commonly  ap- 
pears in  pallid,  unhealthy  children  who  appear  badly 
nourished. 

Etiolog*y.  The  disease  is  never  a  local  affection. 
Formerly,  it  was  classified  as  keratitis  lymphatica  seu 
scrophulosa  and  Hutchinson  was  the  first  to  declare  it 
due,  as  a  rule,  to  hereditary  lues.  At  the  same  time, 
he  called  attention  to  another  symptom  often  found 
with  it  and  considered  as  a  certain  indication  of  exist- 
ent hereditary  syphilis,  viz.  Hutchinson's  teeth  {vide 
Plate  XXXIV.,  Fig.  49). 

By  Hutchinson's  teeth  we  mean  a  dental  form  where 
the  two  middle  upper  incisors  of  the  second  dentition 
have,  instead  of  a  straight  cutting-edge,  a  half-moon 
notch  or  indentation  and  converging  sides.  This 
notching  of  the  free  margin  of  the  tooth  is  commonly 
observable  up  to  the  25th  year,  after  which  the  cor- 
ners are  broken  or  worn  off.  With  this  typical  form 
are  often  found  other  dental  abnormalities,  e.  g.  ab- 
normal smallness  of  the  canines,  wide  intervals  be- 
tween teeth  and  irregular  location  and  formation  of 
the  teeth  in  general. 

Such  teeth  are  not  to  be  confused  with  rachitic 
teeth,  in  which  we  find  horizontal  furrows  and  ridges 
and  defective  enamel  {vide  Plate  XXXIV.,  Fig.  50). 

With  the  two  symptoms  described,  the  interstitial 
keratitis  and  the  Hutchinson's  teeth,  there  is  most  fre- 
quently associated  a  third,  vis.  hard  hearing,  and  this, 
as  a  rule,  without  objective  clinical  cause.  The  three 
phenomena  form  the  so-called  Hutchinson  triad,  and 
they  diagnose  absolutely  the  existence  of  hereditary 

96 


Greeff,   Atlas. 


Tab.  XXX> 


Fig.  51. 
Rhagades  on  face   in  liereditary  Lues. 


;bman  Company.  New  York. 


CL'if,  Atlas. 


Tab.  XXXVl. 


Fig- 
Head  formation  in 


52. 
iiereditary 


I  .lies. 


n  Company,   New  York . 


syphilis.  I  have,  however,  seen  no  case  where  the 
Hutchinson  triad  was  present  and  with  it,  other  symp- 
toms. 

Arlt  and  Forster  have  called  attention  to  a  fre- 
quently occurring  affection  of  the  knee-joint,  either 
preceding  or  following  the  disease. 

Eecently,  more  attention  has  been  given  to  the  fre- 
quent occurrence  of  articular  troubles  in  hereditary 
syphilis.  According  to  Fournier,  these  were  found 
82  times  in  212  cases. 

The  knee  is  most  often  affected,  then  the  elbow, 
more  rarely,  other  joints.  The  articular  inflamma- 
tion generally  precedes  or  develops  with  the  intersti- 
tial keratitis,  seldom  following  it.  The  articular 
trouble  often  develops  on  both  sides  of  the  body. 

We  are  concerned  here  almost  invariably  with 
serous  effusions  into  the  joints,  usually  sequent  to 
moderate,  drawing  pains  and  beginning  without  fever 
or  with  but  slight  elevation  of  temperature.  Accord- 
ing to  Fournier  these  articular  troubles  are  dependent 
upon  affections  of  the  bones,  whilst  other  syphilo- 
graphs  hold  that  they  may  be  primary  synovites. 

We  should  also  note  the  state  of  the  lymph  glands, 
the  peculiar  formation  of  face  and  skull  (vide  Fig.  52, 
Plate  XXXVI.),  the  often  sunken  nasal  bridge  (Fig. 
48),  an  ozena  perhaps  present,  blenorrhea  of  the 
lacrimal  sac,  rhagades  at  the  corners  of  the  mouth  or 
over  the  entire  face  {vide  Plate  XXXV.,  Fig.  51),  etc. 
Together  with  the  objective  findings,  the  anamnesis 
is  important.  Inquiry  should  be  made  concerning  a 
possible  earlier  infection  of  the  parents,  whether  pre- 
mature or  dead  children  preceded  the  birth  of  the  pa- 
tient, whether  many  children  died  in  infancy,  etc. 

Often  a  glance  or  two  will  establish  the  diagno- 
sis ;  often  the  most  careful  investigation  and  examin- 
ation are  necessary,  and  there  will  always  be  cases 

97 


where  hereditary  lues  cannot  be  considered.  In  such 
cases,  other  diseases  are  etiologic,  such  as  scrofula, 
chlorosis,  and  above  all,  tuberculosis.  Of  rarer  etio- 
logic factors,  we  may  mention  articular  rheumatism, 
and  finally,  malaria  and  influenza. 

Course.  The  disease  runs  a  very  slow  course,  its 
briefest  duration  being  several  months  and  it  is  often 
six  months  or  a  year  before  the  inflammatory  phe- 
nomena subside  and  the  opacities  clear  up.  As  an 
average  we  may  reckon  on  a  half  year.  It  is  there- 
fore recommended  that  the  physician  inform  the  pa- 
tient of  the  possible  duration  of  the  disease  and  ad- 
monish him  to  cultivate  fortitude.  And  likewise,  when 
the  disease  begins  in  one  eye,  the  patient  should  be 
told  of  its  rapid  appearance  in  the  other,  lest  he  be 
terrified  at  the  new  outbreak,  and  also  that  he  may 
not  become  suspicious  of  the  therapy  employed. 

The  prog'nosis,  despite  the  fact  that  no  medical 
assistance  can  abbreviate  or  arrest  the  disease,  is  rela- 
tively favorable.  Even  after  long  duration,  the  corneal 
opacities  usually  clear  up,  the  process  commonly  be- 
ginning at  the  margin  so  that  the  center  of  the  cornea 
is  the  last  to  clarify.  As  a  rule,  the  eye  regains  a  fair 
or,  at  least,  endurable  degree  of  vision,  and  rarely  are 
there  any  dense  opacities  left. 

Tberapy  must  be  local  and  constitutional.  In 
the  beginning,  warm,  moist  compresses  commonly  mit- 
igate the  symptoms  of  irritation  and  inflammation. 
The  compress  is  made  by  placing  a  large,  moist  piece 
of  absorbent  cotton  over  the  eye,  then  some  gutta- 
percha tissue  followed  by  a  gauze  roller  to  keep  the 
compress  in  place.  Renewal  of  the  dressing  once  or 
twice  daily  may  be  indicated.  Another  method  of 
attaining  the  same   result  is  frequent  irrigation  or 


bathing  of  the  eye  with  warm  water.  The  warm,  moist 
compress  is  particularly  serviceable  at  night  when  a 
permanent  bandage  is  required.  The  best  solution 
with  which  to  moisten  the  cotton  is  a  2-4%  boric  acid, 
the  ancient  household  friend,  chamomile  tea  is  less 
cleanly,  and  apt  to  carry  dust  particles  into  the  eye.  As 
soon  as  iridic  involvement  is  noted— and  this  is  seldom 
absent — the  first  and  most  important  measure  is  the 
repeated  instillation  of  atropin  (1%)  until  the  pupil 
dilates  fully,  a  procedure  which  must  be  again  prac- 
ticed later  in  the  disease.  If  these  measures  be  neg- 
lected, posterior  synechia,  possibly  complete  occlusion 
of  the  pupil  will  surely  ensue,  and  the  eye  will  be  per- 
manently and  seriously  injured.  Furthermore,  the  eye 
should  be  well  protected  against  the  light  by  moderate 
darkening  of  the  room,  and  later,  by  a  sun  umbrella 
and  protective  eyeglasses. 

When  there  has  been  a  long-continued,  excessive 
vascular  development,  a  peritomy  of  the  cornea  has 
been  done,  /.  e.  with  a  scalpel  a  circular  corneal  in- 
cision through  the  blood-vessels  has  been  made  or  else 
a  circular  strip,  1-2  mm.  wide,  removed  at  the  corneo- 
scleral junction.  Experience,  however,  has  taught 
us  that  the  blood-vessels  unite  again  after  a  time,  and 
a  more  violent  state  of  irritation  has  so  often  followed 
the  operation  that  most  ophthalmologists  have  aban- 
doned it.  If  the  inflammation  have  subsided,  we  en- 
deavor to  clear  up  the  opacity  by  irritant  measures, 
such  as :  the  insuflBation  of  calomel  powder  or  massag- 
ing with  yellow  ointment,  which  is  used  at  the  Berlin 
University  Clinic  in  somewhat  less  strength  than  that 
originally  prescribed  by  Pagenstecher. 

As  already  emphasized,  it  is  extremely  important  to 
note  the  general  constitution  of  the  patient.  In  feeble 
individuals  a  roboraut  diet  is  indicated  (good  food, 
eggs,  meat,  etc.)  and  iodine  preparations  are  partic- 

99 


ularly  desirable  (iodide  of  iron,  cod  liver  oil  with 
iodine,  iodine  mineral  waters).  In  the  later  stages, 
living  in  the  country,  in  good  air,  is  to  be  strongly  rec- 
ommended. 

In  the  numerous  cases  where  hereditary  syphilis  is 
etiologie,  this,  naturally,  should  receive  first  consider- 
ation, using  the  ordinary  remedies,  mercury  and  iodide 
of  potash. 

If  tuberculosis  be  the  specific  cause  or  fundament  of 
keratitis  parenchymatosa,  the  nutrition  of  the  patient 
should  be  first  attended  to.  Internally,  kreosote  or  its 
active  principle,  guaiacol  (which  is  less  unpleasant  to 
the  taste  and  better  borne)  is  recommended. 

Malaria,  of  course,  demands  the  administration  of 
quinine,  and,  in  the  various  forms  of  rheumatism, 
treatment  by  sweating,  together  with  sod.  salicyl.,  as- 
pirin, or  light-baths. 


100 


n 
a. 


■ooZD 

1) 


o 


b/j 


I  Company,  New  York. 


Ulcus  Serpens  Sive  Hypopyon- 
Keratitis. 

Plate  XXXVII.,  Figs.  53-54. 

The  normal  epithelium  of  the  cornea  is  so  dense  in 
structure,  that  the  common  excitants  of  suppuration 
are  unable  to  gain  entrance.  Pus  containing  staphylo- 
or  streptococci  cannot  penetrate  the  intact  cornea, 
and  even  the  virulent  pus  found  in  a  dilated  lacrimal 
sac  and  in  which  pneumococci  are  chiefly  found,  may 
constantly  and  for  a  long  time  flow  over  the  eye  with- 
out causing  any  noticeable  inflammation,  the  cornea, 
at  least,  remaining  unaffected.  Gonococcal  pus  alone 
is  able  to  penetrate  intact  corneal  epithelium,  though 
this  takes  considerable  time,  and  is  due  to  maceration 
of  the  epithelium  by  stagnating  pus.  Other  excitants 
of  suppuration  require  an  artificial  entrance  for  their 
penetration  into  corneal  tissue,  and  such  entrance  is 
usually  due  to  a  wound,  even  if  only  a  slight  and  super- 
ficial abrasion.  If  pyogenic  germs  present  in  the  con- 
junctival sac,  on  or  in  foreign  bodies,  in  the  secretions 
of  the  lacrimal  sac  then  enter  the  wound,  the  colonies 
which  flourish  luxuriantly  beneath  the  epithelium 
cause  its  desquamation  and  there  develops  what  mod- 
ern science  most  suitably  terms  a  septic  ulceration  of 
the  cornea.  It  is  characteristic  of  this  lesion  that  there 
soon  develops  in  the  anterior  chamber  a  collection  of 
pus,  called  a  hy|)opyon  (whence  the  older  nomencla- 
ture, hypopyon-keratitis).  Because  of  its  pronounced 
tendency  to  burrow  rapidly  and  uninterruptibly  be- 

101 


neneath  the  epithelium,  the  name,  ulcus  serpens,  is 
very  descriptive. 

As  soon  as  the  ulcer  has  attained  a  certain  growth, 
iritis  regularly  sets  in. 

In  Fig.  53  is  seen  the  disk-shaped  ulcer  with  its  yel- 
low, up-turned  margin.  The  circumjacent  cornea  is 
edematously  opaque  and  misty.  Below,  in  the  ante- 
rior chamber  lies  the  narrow,  sickle-shaped  hypopyon, 
and  a  commencing  pericorneal  injection  denotes  the 
initiation  of  an  iritis. 

Fig.  54  shows  an  ulcus  serpens  which  has  destroyed 
the  greater  part  of  the  cornea.  The  hypopyon  fills 
more  than  half  of  the  anterior  chamber.  There  is  a 
slight  palpebral  swelling,  and  a  marked  pericorneal 
injection  denotes  the  existence  of  an  intense  iritis  which 
we  are  no  longer  able  to  observe  directly. 

Prog'nosis.  Ulcus  serpens,  a  frequent  and  se- 
rious disease  of  the  eye,  will,  if  left  to  itself,  lead 
within  a  few  days  to  permanent  blindness.  It  is,  there- 
fore, a  grave  condition  and  the  cause  of  much  blind- 
ness. After  eating  off  the  entire  surface  of  the  cor- 
nea, the  process  commonly  works  downward  until  a 
rupture  occurs,  after  which  it  usually  halts.  The  loss 
of  substance  caused  by  it,  is  replaced  with  scar-tissue. 

Tberapy.  In  many  cases  the  source  of  infection 
is  in  some  diseased  condition  of  the  lacrimal  sac, 
which  should  be  split  open  from  the  outside  and  tam- 
ponned  with  iodoform  gauze  or  else  thoroughly  ex- 
tirpated, for  the  use  of  the  sound  is  profitless.  Every 
two  hours  a  few  drops  of  undiluted  and  freshly  pre- 
pared aqua  chlori  should  be  poured  upon  the  ulcer, 
when,  if  it  still  advances,  the  platinima  loop  should  be 
used  in  cauterizing  the  edges.  Application  of  iodo- 
form powder  follows  the  cauterization,  or  better,  airol 
in  the  form  of  a  fine  powder  placed  within  the  con- 

102 


junctival  sac  where  it  forms  a  paste,  soon  hardening 
to  a  firm  crust  over  the  ulceration.  In  far-advanced 
eases  the  cornea  should  be  obliquely  split  (method  of 
Samisch). 

A  pneumococcic  serum  has  been  manufactured  lately 
and  used  subcutaneously  with  success  in  ulcus  serpens. 


103 


LeucomaCorneae  from  Variola 

Vera. 

Plate  XXXVni.,  Fig.  55. 

Only  the  epithelium  of  the  cornea  regenerates  and 
becomes  transparent  again.  After  destruction  of  cor- 
neal substance,  there  develops  an  opaque  cicatrix  of 
various  degrees  of  density  and  thickness,  according  to 
the  thickness  of  the  lost  substance.  A  delicate,  super- 
ficial, yet  visibly  gray  scar  is  called  a  nubecula;  a 
thicker  one,  macula;  a  perfectly  opaque,  white  scar, 
a  leucoma  corneae. 

This  last  form  is  either  partial,  as  in  Fig.  35,  Plate 
XXIV.,  or  total,  as  in  Fig.  55. 

In  many  leucomas,  a  piece  of  the  iris  has  become  ad- 
herent, forming  a  synechia  anterior  or  leucoma  ad- 
haerens  (seen  in  Fig.  35  above  the  black,  streak-like 
scar),  a  sign  that  perforation  of  the  cornea  has  taken 
place. 

Therapy.  In  thick  leucomas  there  is  nothing  to 
be  hoped  for  from  therapeutics  or  from  time.  If  they 
cover  the  entire  pupil,  vision  is  lost  save  for  a  sense 
of  light.  If  partial,  an  artificial  pupil  may  be  inserted 
in  the  remaining  portion  of  the  cornea  (vide  Fig.  35 >. 
To  lessen  the  disfigurement,  India  ink  has  been  stip- 
pled into  the  leucoma,  thus  simulating  more  the  black 
iridic  aperture. 

In  slight  corneal  opacity,  a  certain  degree  of  cure  is 
got  through  time  alone.  This  may  be  accelerated  by 
irritants  (insufiflation  of  calomel,  pencilling  over  with 

104 


eff,  Atlas. 


Tab.  XXXVIII. 


Fig.  55 
Leucoma  corneae  totale. 


yellow  mercuric  oxide  salve,  2-5%,  and  by  hot  va- 
pors), to  induce  more  rapid  metabolism,  but,  such 
therapy  is  suitable  only  tn  fresh  cases.  Recently  dionin 
(5-10%  sol.,  later  in  substance  or  powder  form)  has 
been  much  recommended. 

There  are,  also,  congenital  opacities;  the  corneae  of 
both  eyes  have  a  milky  and  sclerotic  appearance.  These 
opacities  are  not  defects  of  development,  as  formerly 
believed,  but  the  residua  of  a  keratitis  interstitialis  in 
utero  e  lue  hereditaria.  Treatment,  then,  must  be 
antisyphilitic. 

A  non-inflammatory,  physiologic  opacity  is  the  arcus 
senilis  or  gerontoxon  corneae,  appearing,  sooner  or 
later,  with  advancing  age.  The  opacity  is  character- 
istic— a  narrow,  gray  line,  concentric  with  the  corneal 
margin.  It  almost  invariably  begins  at  a  point  in  the 
superior  margin;  then  the  lower  margin  develops  a 
similar  bow  or  arch.  With  the  further  extension,  the 
superior  and  inferior  sections  meet  at  the  inner  and 
outer  sides,  and  the  ring  or  circle  of  the  arcus  senilis 
is  complete.  Its  outer  side  is  sharply  marked  and  in- 
variably separated  from  the  limbus  by  a  strip  of  trans- 
parent cornea  (vide  Plate  L.,  Fig.  74). 

Prog'nosis.  The  arcus  senilis  is  not  a  progress- 
ive opacity,  for  when  the  circle  is  completed  and  has 
attained  a  breadth  of  1-2  mm.  the  process  stops. 

To  the  non-inflammatory  corneal  turbidities  belongs 
the  girdle-like  or  ribbon-shaped  opacity  {vide  Plate 
XXV.,  Fig.  36).  It  is  a  broad,  white  band  (2-4  mm. 
in  breadth)  extending  horizontally  just  below  the  mid- 
dle of  the  cornea.  A  narrow,  transparent  line  of  nor- 
mal corneal  tissue  separates  the  opaque  band  at  its 
two  extremities  from  the  corneal  margin.  It  develops 
slowly  in  the  course  of  years  and  usually  in  eyes  blind- 
•ed  by  an  insidious  irido-chorioiditis.     It  is  due  to  a 

105 


deposition  of  lime  salts   following   a   disturbance   of 
nutrition  in  the  cornea. 

Therapy.  There  is  none.  As  it  generally  devel- 
ops in  eyes  already  blind,  it  is  a  condition  of  no  prac- 
tical significance. 


106 


ccff,  Atlas. 


a. 


lO    ^ 


b£< 


X 


lO   c 

o 

bi-S 


binjii  Company,  New  York. 


reeti,  Alias. 


lat).  f 


Fig.  58. 
Buphthalmus.   Cornea  globosa. 


I^tbMi;iri  Company,  New  York. 


Ectasias  of  the  CorncaB. 

Plate  XXXIX.,  Fig.  56:  Keratoconus. 

Plate  XXXIX.,  Fig.  57 :  Staphyloma  corneae  partial*^ 

Plate  XL.,  Fig.  58:  Cornea  globosa;  Buphthalmia. 

Plate  X  LI.,  Fig.  59 :  Staphyloma  cornese  totale. 

(a)  Among  corneal  ectasias,  staphyloma  cornese 
should  be  first  mentioned.  It  is  com])osed  of  a  iiro- 
lapsed,  cicatrised  iris,  and,  therefore,  at  its  point  of 
exit,  the  cornea  has  been  entirely  destroyed,  and  the 
intraocular  pressure  forces  forward  the  yielding  cica- 
tricial tissue  of  the  iris.  We  differentiate  a  staphylo- 
ma partiale  (Fig.  57)  and  totale  (Fig.  59).  At  first, 
and  with  small  staphylomas,  the  black  pigment  of  the 
iris  is  predominant  in  the  extruding  mass,  but  later 
the  iris  becomes  so  cicatrized  and  enlarged  that  the 
staphyloma  appears  gray-white,  traversed  by  dilated 
blood-vessels. 

Staphyloma  is  the  end-product  of  a  corneal  sup- 
puration. Its  genesis  is  shown  in  the  left  eye  of  Fig. 
38,  Plate  XXVI.,  where  we  see  how,  after  destruction 
of  the  cornea,  there  has  developed  a  total  prolapse  of 
the  iris,  which  has  already  begun  to  buckle  forwards. 

Therapy.  A  partial  staphyloma  must  be 
removed.  The  open  wound  then  closes  usually  with 
firmer  connective  tissue  than  the  delicate  iridic  tis- 
sues are  capable  of  producing. 

After  removal  of  a  total  staphyloma,  the  resulting 
large  wound  is  best  sutured  together,  which,  however, 
leaves  but  the  stump  of  an  eye. 

107 


(b)  Keratoconus  is  a  rare  disease  generally  af- 
fecting both  eyes.  Very  gradually  and  with  no  in- 
flammatory phenomena,  the  central  portion  of  the 
cornea  begins  to  protrude  forwards,  cone-like.  This 
corneal  area  remains  transparent  for  a  long  time,  un- 
til finally  the  apex  of  the  cone,  subjected  as  it  is  to 
enormous  dilatation,  begins  to  develop  opacity  from 
cicatrization. 

The  etiology  of  the  disease  is  unknown.  Because 
of  some  disturbance  of  nutrition  the  central  portion 
of  the  cornea  becomes  thinner  and  hence  so  much  the 
less  able  to  withstand  the  anteriorly  directed  intraoc- 
ular pressure. 

Therapy  is  rather  impotent.  In  conjunction  with 
a  strengthening  diet,  the  instillation  of  a  miotic  (eserin, 
pilocarpin)  may  be  practiced  for  a  long  period  to  re- 
duce permanently  the  intraocular  pressure,  though  an 
iridectomy  for  the  same  purpose  is  better  The  apex 
of  the  cone  may  be  destroyed  by  galvanic  cautery  in 
order  to  obtain  a  more  resistant  cicatrix. 

(c)  Keeatoglobus-Buphthalmus.  In  keratoglo- 
bus  or  cornea  globosa,  the  transparent  cornea  in  all 
its  parts  is  symmetrically  thrust  forward,  so  that  in- 
stead of  its  normal  "watch-glass"  projection  from 
the  globus,  its  form  resembles  that  of  a  "cover- glass" 
used  to  protect  cheese.  It  is  only  one  of  the  phenom- 
ena accompanying  the  general  enlargement  of  the  eye- 
ball in  hydrophthalmus  or  buphthahnus  or  the  total 
sclerectasia  resulting  from  increase  of  pressure  in  the 
eye  of  childhood,  whilst  the  sclera  is  still  yielding  in 
its  structure  (in  the  first  years  of  life).  We  have, 
therefore,  an  infantile  glaucoma. 

The  nature  of  the  disease,  however,  is  not  fully  un- 
derstood. Possibly  it  is  due  to  a  congenital  misplace- 
ment of  the  natural  exits  for  ocular  fluids. 

108 


rcetf.  Athis. 


Tab.   XI 


Fig.  59. 
Staphyloma  orneae  totale. 


hiiiaii  Company,  New  York. 


The  eye  is  often  enormously  enlarged  in  its  periph- 
ery, and  the  attenuated  sclera  is  bluish  because  of  the 
perlucence  of  the  chorioid.  Anteriorly,  the  enlarged 
cornea,  of  a  misty  or  milky-white  opacity,  stands  out 
like  a  cheese  cover  glass  against  the  bulbus.  The  an- 
terior chamber  is,  likewise,  very  deep. 

Prog'nosis  is  most  unfavorable,  and,  left  alone, 
the  process  gradually  leads  to  absolute  blindness,  very 
rarely  halting  in  its  progress.  Anatomically,  there  is 
a  total  glaucomatous  excavation  of  pupil  and  globe. 

Therapy.  It  is  very  advisable,  to  perform,  as 
soon  as  possible,  a  broad  iridectomy  or  sclerectomy. 


109 


Lepra. 

Plate  XLIl.,  Fig.  60;  Plate  XLIII.,  Fig.  61. 

Lyder  Bortlien  emphasizes  as  an  important  phe- 
nomenon, that  the  outbreak  of  the  nodular  form  of 
lepra  almost  always  begins  in  the  eyebrows.  It  is  di- 
agnostically  valuable  to  know  that  the  loss  of  the  eye- 
brows is  the  first,  and  sometimes  for  years,  the  only 
sign  of  the  disease.  As  initial  symptom  in  the  eye- 
brows, the  formation  of  nodules  is  more  frequent  than 
diffuse  infiltration.  The  eyelashes  also  are  regularly 
involved.  The  disease  consists  of  the  falling  out  of 
the  hair,  or  atrophy,  partial  or  total. 

The  skin  of  the  eyelids  is  frequently  and  early  dis- 
eased, either  infiltrated  or  nodulated.  The  infiltration, 
often  edematous  in  appearance,  may  be  synchronous 
with  that  of  the  eyebrows,  or,  separated  from  it  by 
healthy  skin,  may  occur  along  the  margins  of  the  lids. 

In  the  lids,  the  nodes  themselves  are  particularly 
large,  and  most  often  located  along  the  free  palpebral 
margin.  It  is  peculiar  that  the  lid-nodules  may  ap- 
pear symmetrically  on  the  correspondent  eyelids. 

The  maculo-anesthetic  type,  i.  e.  blotches  or  spots, 
is  also  often  found  in  the  eyebrow  though  not  so  fre- 
quently as  in  nodular  leprosy. 

If,  in  the  nodular  type,  an  infiltrated  area  of  the 
skin  of  the  eyebrow  be  excised  and  the  humor  pressed 
out,  the  diagnosis  may  be  rendered  certain  by  demon- 
stration of  the  lepra  bacillus. 

The  disease  seems  to  begin  in  the  middle  layers  of 
the  skin,  and  usually  in  the  center  of  the  node  a  blood- 

110 


reeff,  Atlas. 


Tab,   XL 


Fio-.   60. 
Lepra.     Keratitis  punctata. 


brn.Tti  Company,  New  York 


Fig.  61. 
Lepra.  —  Efiipulbar  l.eprome. 


^brn.Tii  Company,  New  York 


vessel,  lymph-channel,  often  a  capillary,  is  demon- 
strable. The  bacilli  are,  therefore,  carried  by  both  the 
blood  and  lymph  systems.  Not  rarely  they  are  found 
in  the  cells  of  the  intima,  seldom  in  the  white  cor- 
puscles in  the  lumen  of  the  blood-vessel.  If  capillaries 
or  small  vessels  are  the  points  of  nodule  formation, 
marked  dilatation  with  hemic  engorgement  occurs  with 
the  bacillary  invasion.  Infiltration  of  the  tissues  sur- 
rounding the  vessels  develops  late,  and  only  when  the 
bacilli  begin  to  flourish  outside  of  the  vessel.  Then 
there  occurs  an  accumulation  of  emigrated  leucocytes 
and  a  great  increase  of  nuclei  through  the  prolifera- 
tion of  the  fixed  cells  of  the  connective  tissue. 

Further  growth  of  the  node  is  accomplished  by  the 
bacilli  attacking  the  cells  adjacent  to  the  blood  or 
lymph  channel.  The  leprous  virus  is  by  no  means  as 
active  as,  for  example,  that  of  the  tubercle  bacillus, 
wliich,  in  a  comparatively  short  time,  kills  the  cells. 
Hence,  in  lepra  nodes  many  bacilli  can  be  seen  in  cells 
of  normal  appearance  and  still  retaining  their  power 
of  proliferation.  This  minimal  tendency  to  destruc- 
tion of  cells  permits  leprous  proliferations  to  take  on 
the  appearance  of  veritable  tumors  (H.  P.  Lie). 

Affections  of  the  eyeball  are  frequent,  in  fact,  al- 
most the  rule,  in  lepra,  and  the  most  common  is  a  kera- 
titis punctata  or  nodosa,  in  which  small  white  or  gray 
nodules  develop  beneath  the  epithelium  with  very  little 
ophthalmic  irritation  {vide  Fig.  60).  The  nodules  are 
chiefly  composed  of  lepra  bacilli. 

A  true  keratitis  parenchymatosa  with  iritis  is  not 
infrequent. 

Finally,  the  granulation-tumors  described  as  on  the 
lids  are  also  found  as  epibulbar  upon  the  cornea,  and, 
as  with  other  epibulbar  tumors  they  extend  outwards 
from  the  limbus  corneae. 


Ill 


Scleritis.    Sclerectasia. 

Plate  XLIV.,  Fig.  62 ;  Plate  XLV.,  Fig.  63. 

In  inflammation  of  the  sclera  we  may  differentiate 
forms  affecting  only  the  superficial  layers  (epi- 
scleritis)  from  a  true  scleritis,  confined  to  the  middle 
and  deep  strata. 

In  the  superficial  form  there  is  usually  first  found 
a  circumscribed  morbid  focus  close  to  the  cornea.  The 
area  is  puffed  up,  and  forms  a  more  or  less  steep  hill- 
ock or  hump,  at  first  dark-red  and  later  more  of  a 
blue  or  violet  hue.  It  is  hard  to  the  touch,  not  mov- 
able, and  very  sensitive.  Toward  it  and  through  it 
run  dark-red,  deep-lying  (episcleral)  blood-vessels, 
and  the  injected  conjunctiva  covering  it  is  movable. 
The  ocular  surface  elsewhere  is  almost  non-irritable 
(vide  Fig.  62). 

This  infiltration  shows  little  tendency  to  destruc- 
tion of  tissue  or  to  ulceration,  and  sooner  or  later  the 
exudate  is  resorbed,  though  commonly  with  the  de- 
struction of  some  scleral  tissue,  for,  in  the  area  of  in- 
flammation, the  sclera  has  a  delicate  smoke-gray  tint 
which,  with  a  higher  degree  of  intensity,  becomes 
slate-gray.  We  have  to  do,  then,  with  an  attenuation 
of  the  sclera  (cicatrized  tissue)  through  which  the 
black  chorioid  shimmers,  but,  however,  much  less 
noticeable  in  this  superficial  form  than  in  the  deeper. 
The  bulbus,  furthermore,  is  commonly  not  injured. 

The  deep  form  of  scleritis  is  rarer,  and  at  first  more 
diflScult  to  diagnose,  for  it  is  not  possible,  without 
autopsy  or  dissection,  to  determine  how  deep  the  scle- 

112 


[■cff,  Atlas. 


Tab.  XLIV 


Fig.  62. 

Scleritis. 


bm.Ki  Company,  New  Yorl<. 


Ireeff,    Alias. 


Tab.  XLV 


Fig-.  63. 
Sclerectasia. 


man  Company.  New  York 


rotic  inflammation  extends.  We  deduce  this  from  the 
unfailing  involvement  of  other  ocular  membranes 
(iritis,  chorioiditis,  sclerosing  keratitis),  and  hence 
the  disease  is  called  scleritis  complicata  by  many  au- 
thors, and  develops  during  its  course  the  resultant 
marked  thinning  of  the  sclera,  whose  rupture  is  due  to 
intraocular  pressure.  At  the  beginning  we  again  find 
a  dark-red  or  bluish  hump-like  projection  or  swelling 
in  the  affected  area.  The  projection,  in  general,  is  not 
sharply  circumscribed  and  has  a  great  tendency  to  ex- 
tend farther,  so  that  later,  the  entire  cornea  is  sur- 
rounded by  these  elevations. 

In  this  form,  also,  there  occurs  no  direct  disintegra- 
tion, and  there  is  left,  finally,  only  a  marked,  cicatricial 
thinning  of  the  sclera,  often  so  prominent  that  the 
chorioid  beneath  shimmers  through  with  a  bluish  tint. 
Often,  however,  after  resorption  of  the  exudate,  the 
sclera  has  lost  so  much  of  its  firmness  that  it  is  unable 
to  offer  sufficient  resistance  to  the  intraocular  pres- 
sure, and  there  results  a  bulging  out, — ectasia, — of 
the  affected  areas. 

Fig.  63  shows  such  anterior  scleral  staphylomata, 
which,  because^  they  often  surround  the  cornea  like  a 
ring,  are  termed  annular  staphylomata.  In  such  cases, 
however,  the  staphylomata  do  not  become  entirely  con- 
fluent, but  between  the  individual  lumps  there  are  al- 
ways retractions,  so  that  the  comparison  with  a  piece 
of  large  intestine  or  black-pudding  sausage  (Blut- 
WTirst)  is  not  inapplicable. 

The  eye  in  Fig.  63  is  held  open  by  the  Desmarre 
speculum ;  in  Fig.  62  by  the  von  Grafe  dilator. 

Scleritis,  therefore,  is  an  extremely  chronic  disease, 
developing  in  middle  and  old  age.  Relapses  are  easy. 
Fundamentally,  gout,  tuberculosis,  syphilis  or  rheu- 
matism is  causative. 


113 


Prognosis  in  the  superficial  form  is  fairly  good, 
if  we  do  not  consider  the  long  duration  of  the  disease. 
In  the  deep  form,  blindness  is  a  frequent  sequela 
(pupillary  atresia,  secondary  glaucoma,  etc.). 

Therapy  is  somewhat  powerless.  Atropin  to  full 
dilatation  of  the  pupil,  warm,  moist  compresses,  wet 
packs,  eventually  subconjunctival  injection.  The 
nodes  may  be  massaged  with  mercurial  ointment. 

Constitutional  treatment,  according  to  the  nature 
of  the  fundamental  affection,  is  very  important.  If 
increase  of  intraocular  pressure  develop,  iridectomy 
is  indicated. 


114 


Cll,    Atl.lS. 


Fig.  64. 
Iritis,     i'apulous  Syphilite. 


Fig.  65.     Synecliiae  posteriores  following  Iritis 


Fig.  66.     Condylomata  iridis. 


iiiati  Ci)ni|i;iMy,  New  York. 


Iritis. 

Plate  XLVI.,  Figs.  64-66;  Plate  XL VII.,  Figs.  67-69. 

Iritis  is  a  common  and  serious  lesion,  and  knowl- 
edge of  it  is  essential  to  every  practicing  physician, 
for  its  non-recognition  or  improper  treatment  will 
lead,  in  a  few  days,  to  adhesions  of  the  iridic  margin 
wliich  cannot  be  corrected,  disabling  the  patient  dur- 
ing his  entire  life,  even  if  such  neglect  do  not,  as  is 
common,  finally  lead  to  loss  of  the  eye. 

The  sjTnptoms  of  iritis  are:  (1)  A  pericorneal  or 
episcleral  injection  (vide  Plate  XLVI.,  Fig.  64)  com- 
posed of  violet-red,  deep  blood-vessels,  branching  like 
the  wisps  of  a  broom,  close  to  and  surrounding  the 
cornea  like  a  ring.  These  vessels  lie  beneath  the  con- 
junctiva upon  the  sclera,  and  by  their  marginal 
branchings  nourish  the  deep  layers  of  the  cornea  and 
then,  at  the  junction  of  cornea  and  sclera,  turn  in- 
ward and  penetrate  to  the  iridic  attachment.  In  vio- 
lent inflammations,  not  only  is  the  red  ring  around  the 
cornea  present,  but  the  entire  eyeball  is  red.  We 
must,  however,  verify  that  the  redness  augments  as 
it  approaches  the  corneal  margin,  whilst  in  simple 
conjunctival  redness  it  decreases  {vide  Plate 
XXX^^L,  Fig.  54). 

(2)  Alterations  in  the  pupil.  Very  early  the  pupils 
contract  and  exhibit  a  tardy  reaction  (because  of 
cramp  in  the  muse,  sphincter  iridis).  If  left  in  this 
contracted  state,  fibrinous  exudates  develop  on  the 
posterior  surface  and  adhere  to  the  anterior  capsule 
of  the  lens  (synechiae  posteriores),  first  at  one  point, 

115 


then  at  several,  finally  including  the  entire  iris.  The 
synechifE  are  sometimes  first  seen  after  the  instilla- 
tion of  atropin,  when  the  free  areas  of  the  iridic  mar- 
gin respond  with  dilatation  whilst  the  adherent  areas 
are  directed  inwards  like  well-defined  serrations  {vide 
Plate  XLVI.,  Fig.  C5;  also,  Figs.  67-68). 

Finally,  in  the  still  free,  contracted  pupil,  surround- 
ed by  adhesions,  a  fibrinous  deposit  may  be  observed, 
entirely  occluding  the  pupil :  Occlusio  pupillae,  due  to 
an  inflammatory  membrane  {vide  Plate  XLVII.,  Fig. 
69). 

(3)  Changes  in  iridic  tissue.  The  hyperemia  of  the 
iris  soon  leads  to  a  change  of  color,  so  that  the  blue 
iris  becomes  a  dirty  green,  the  brown  iris  a  rusty  red. 

In  some  few  cases,  characteristic  nodules  form  on 
the  surface  of  the  iris.  Those  appearing  on  the  pupil- 
lary margin,  multiple,  and,  because  of  the  rich  vascu- 
lar supply,  having  an  orange-yellow  tint,  are  to  be 
considered  as  luetic  papules  or  condylomata  {vide 
Plate  XLVL,  Fig.  66). 

The  pale-gray  tubercles,  poor  in  blood-vessels,  are 
mostly  shown  about  the  small  iridic  circumference  or 
in  the  corner  of  the  anterior  chamber  (Plate  XLVII., 
Fig.  68). 

Gummata  may  develop  as  large  yellow  nodes,  usu- 
ally isolated  (Plate  XLVII.,  Fig.  67). 

(4)  The  cornea  is  often  mistily  opaque. 
Subjectively,  we  have  photophobia,  lacrimation,  and 

frequently  violent  pains,  which  may  extend  to  the  fore- 
head and  temples. 

Course  of  the  disease.  Iritis  may  be  either 
extremely  insidious  or  else  violent  with  much  pain.  It 
is  always  to  be  considered  as  a  very  serious  lesion. 
Its  course  may  extend  over  weeks  or  months,  the  pe- 
riod depending  largely  upon  the  treatment. 

116 


Etiologrically,  it  should  be  thoroughly  under- 
stood that  we  are  dealing  with  a  constitutional  dis- 
ease, for  the  idiopathic  iritis  of  olden  times  does  not 
exist. 

Most  often  a  new  syphilitic  infection,  acquired  some 
months  previously,  is  etiologic,  but  it  is  also  found  in 
old  cases.  Next  in  frequency  as  an  etiologic  factor  is 
tuberculosis,  and  the  iritis  is  directly  due  to  metastasis 
from  some  gland. 

It  is  not  a  rare  metastasis  in  gonorrhea,  and  may 
develop  even  after  the  urethral  lesion  has  been  cured. 

As  a  rare  phenomenon  it  may  occur  in  various  in- 
fectious diseases. 

That  a  simple  iritis  may  be  caused  by  a  violent  cold 
is  very  dubitable. 

Naturally,  disease  germs  entering  the  eye  through 
an  abraded  or  injured  surface  may  develop  an  iritis 
traumatica. 

Prognosis,  when  correct  treatment  has  been  em- 
ployed, is  commonly  good,  and  in  the  great  majority 
of  cases,  the  eye  may  be  spared  any  injury,  whilst  by 
non-recognition  of  the  trouble  the  eye  may  be  se- 
riously and  permanently  injured  or  lost  within  a  few 
days. 

Therapy.  In  iritic  inflammation  atropin  is  the 
greatest  remedy ;  by  its  narrowing  of  the  iris  the  blood 
supply  is  lessened,  and  it  hinders  the  development  of 
adhesions  between  the  pupillary  margin  and  the  cap- 
sule of  the  lens  (posterior  synechia).  With  an  in- 
flamed iris,  mydriasis  is  much  more  difiScult  than  when 
the  iris  is  normal.  The  action  of  the  drug  is  accent- 
uated if  used  warm  and  cocain  added  (thus  dilating 
the  lymph  spaces  and  increasing  the  resorptive  pow- 
ers).   Atropin  (1%)  is  instilled  6-12  times  at  inter- 

117 


vals  of  a  few  minutes  until  the  pupil  is  fully  dilatod, 
or  it  is  seen  that  adhesions  have  already  formed  and 
hence,  further  dilatation  is  impossible.  After  mydri- 
asis is  obtained,  the  pains  usually  abate.  Cold  is 
poorly  borne;  warm  compresses  (chamomile  or  boric 
acid  2-4%)  are,  on  the  contrary,  very  helpful;  event- 
ually, warm,  moist  packs  are  indicated;  where  the 
pains  persist,  cupping  of  the  temporal  region  may  be 
resorted  to.  Thorough  sweating  (Schwitzkuren)  often 
affords  marked  relief.  If  an  annular  posterior 
synechia  exist,  iridectomy  should  be  done  after  sub- 
sidence of  the  inflammation,  in  order  to  avoid  second- 
ary glaucoma. 

Above  all  else,  the  etiology  of  the  iritis  should  be 
determined,  and  the  indicated  constitutional  treatment 
pursued. 


118 


irccif,  Atlas. 


ab.  XI.VI 


Fig.  Gt. 
Gumma  iridis.      Syiiecliiac  posteriores 


Fig.  68. 
Tubercles  of  tiie  iris.     Synechiae  posteriores. 


o)'-?i 


Fiff.  69. 
Occlusio  pupillae 
Alembrana  pupiiiaris  infiammatoria. 


Fig.  70. 
.Wembrana  papillaris  perseverans. 


laii  Conip.iny,   Ne\i'  York  . 


Congenital  Anomalies  of  the 

Iris. 

I.     Coloboma  Iridis  Congenitum. 

Plate  XLVIII.,  Fig.  71. 

II.     Membrana   Pupillaris   Perseverans. 

Plate  XLVII.,  Fig.  70. 


Coloboma  iridis  congenitum  may  be  subdivided  into 
a  typical  and  an  atypical  form.  In  the  typical  form, 
there  is  a  split  or  fissure  in  the  iris,  inclining  down- 
wards and,  sometimes,  a  little  towards  the  nose.  Its 
form  resembles  most  that  of  a  Gothic  window,  the 
apex  extending  either  to  the  ciliary  edge  (coloboma 
fotale),  or  the  process  stops  before  it  reaches  the  line 
of  the  eyelashes  (coloboma  partiale).  The  coloboma, 
with  its  apex  invariably  rounded  off,  enters  into  the 
pupilla,  and,  in  this  area  there  are  sometimes  found, 
extending  in  a  horizontal  direction,  cords  or  strings  of 
connective  tissue  passing  over  the  coloboma,  (bridge 
coloboma,  Briiekenkolobom).  An  unpigmented  band 
or  cord  extending  downwards  is  termed  pseudo-colo- 
boma. 

Of  atypical  colobomata  there  are  numerous  reports 
in  the  literature,  the  defects  extending  in  all  direc- 
tions. 

The  congenital  coloboma  is  the  result  of  imperfect 
closure  of  the  palpebral  fissure  in  utero. 

119 


n. 

The  membrana  jmpillaris  perseverans,  the  re- 
mainder of  fetal  pupillary  membrane,  is  not  extremely 
rare.  It  is  differentiated  from  inflammatory  deposits 
upon  the  capsule  of  the  lens  by  the  fact  that  the 
threads  or  cords  of  tissue  never  have  origin  in  the 
pupillary  margin,  but  always  upon  the  anterior  sur- 
face of  the  iris,  most  commonly  from  the  circulus 
arter.  iridis  minor. 

In  the  fetal  eye  it  is  well  known  that  the  hyaloid  ar- 
tery passes  forward  through  the  central  canal  (canalis 
Cloqueti)  of  the  vitreous.  On  reaching  the  posterior 
pole  of  the  lens,  it  branches  and  forms  a  vascular  net- 
work, the  membrana  capsularis,  investing  the  entire 
posterior  surface  of  the  lens.  These  vascular  branches 
pass  over  to  the  anterior  surface  of  the  lens  and  unite 
there  with  blood-vessels  derived  from  the  anterior 
surface  of  the  iris  (especially  those  from  the  circulus 
arteriosus  irid.  minor).  In  the  pupillary  region,  a 
membrane  thus  developed,  is  called  the  membrana 
pupillaris. 

Fragments  of  the  pupillary  membrane  are  not  in- 
frequently noted  but  it  is  extremely  rare  to  find  por- 
tions of  the  membrana  capsularis  on  the  posterior  sur- 
face of  the  lens. 

The  normal  pupillary  membrane  in  the  fetus  is 
finely  granular  with  oval  nuclei  irregularly  distrib- 
uted in  it.  The  anterior  surface  is  covered  with  an 
epithelium  at  first  unimpaired  and  continuous,  but 
later  it  becomes  more  and  more  defective.  On  the 
posterior  surface,  blood-vessels  covered  with  an  endo- 
thelium spread  out.  With  retrogression  of  the  dis- 
ease, the  epithelium  disappears  first,  then  the  blood- 
vessels, and  the  membrane  itself  serves  as  endothe- 
lium for  the  iris. 

120 


The  membrane,  when  it  persists,  is  found  to  be  a 
tough  tissue,  poor  in  nuclei,  but  with  scattered  pig- 
ment cells.  Upon  both  the  anterior  and  posterior  sur- 
faces, the  layer  of  endothelium  is,  usually,  imperfect. 
The  filaments  or  threads  directly  penetrate  the  iridic 
tissue  from  whose  structure  they  cannot  be  differen- 
tiated. The  blood-vessels  in  it  are  abnost  invariably 
empty. 


121 


Glaucoma. 

Plate  XLVIII.,  Fig.  72. 

The  essential  nature  of  glaucoma  (griiner  Star)  is 
the  heightened  pressure  within  the  globe.  It  may  de- 
velop rapidly  (glaucoma  aeutum  or  inflammatoi'ium ) 
or  very  gradually  (glaucoma  chronicum  or  simplex). 

The  actual  reason  for  the  increase  in  pressure  is  not 
known.  Anatomically,  we  usually  find  the  angle  of  the 
anterior  chamber  where  the  humor  is  drained  off 
through  the  spaces  of  Fontana  into  the  canal  of 
Schlemm,  occluded  by  inflammatory  adhesions. 

True  glaucoma  generally  exhibits  prodromal  symp- 
toms. The  patient,  from  time  to  time,  has  obscuration 
of  vision,  sees  as  through  a  fog,  and  lights  used  for 
illuminating  purposes  (candle,  gas,  etc.)  are  sur- 
rounded by  colors,  rainbow  tints :  stadium  prodromale. 
These  phenomena  may  be  called  forth  by  slight  in- 
crease in  pressure. 

Earlier  or  later,  more  violent  attacks  occur:  sta- 
dium evolutum.  In  acute  glaucoma  there  is  marked 
pericorneal  injection,  violent,  even  unbearable,  pains. 
The  cornea  is  mistily  opaque,  the  anterior  chambei 
much  diminished  in  volume,  the  iris  discolored,  the 
pupil  spontaneously  enlarged,  and  vision,  more  or  less 
noticeably  impaired.  The  bulbus  is  distinctly  hard  to 
the  touch. 

In  chronic  cases  all  these  phenomena  of  inflamma- 
tion are  absent,  and,  generally,  the  increase  in  pres- 
sure is  not  felt  manually.  The  patient  is  conscient 
only  of  poor  vision.    Diagnosis  is  best  and  earliest  as- 

122 


ireeff,  Atlas. 


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m;iii  Company,  New  York. 


certained  by  determining  the  limits  of  the  field  of 
vision,  which  starting  from  the  periphery  diminishes 
slowly  but  continuously  by  sectors,  particularly  on 
the  nasal  side.  If  this  diminution  be  already  notice- 
able, then  the  second  sure  sjrmptom  of  chronic  glau- 
coma is  present,  i.  e.  the  ophthalmoscopically  visible 
excavation  of  the  papilla  nervi  optici. 

Left  undisturbed,  the  disease  leads  surely,  sooner 
or  later,  to  absolute,  incurable  blindness:  glaucoma 
absolutura. 

All  the  optic  nerve  fibres  are  broken  at  the  margin 
of  the  deep,  kettle-like  excavation  and  become  atro- 
phied. Later,  there  almost  invariably  develops  a  to- 
tal opacity  of  the  lens. 

Therapy.  The  miotics,  physostigmin  (=eserin) 
and  pilocarpin  are  suitable  remedies  for  reducing  the 
pressure.  They  act  as  long  as  the  iris  is  not  atrophic ; 
i.  e.  as  long  as  it  is  capable  of  contraction.  Their  ac- 
tion, also,  is  not  permanent,  for  with  the  subsidence 
of  miosis,  the  heightened  pressure  returns,  so  that 
we  have  only  palliative,  not  curative,  remedies.  Be- 
ware of  atropin,  for  it  augments  intraocular  pressure. 
If  the  diagnosis  of  glaucoma  is  absolutely  sure,  iridec- 
tomy should  be  done  as  soon  as  possible.  Other  au- 
thors recommend  sclerotomy  in  its  stead. 

Generally,  one  may  expect  to  save  whatever  vision 
is  left  by  a  well-executed,  broad,  peripheral  iridec- 
tomy. 


123 


Disturbances  of  Iridic  IVIotility. 

Plate  XLIX.,  Fig.  73  (Tabes). 

Disturbances  of  iridic  motility  are  shown  by  the 
behavior  of  the  pupil. 

Normal  pupils  are,  as  a  rule,  equally  large,  whilst 
inequality  (anisocoria)  always  indicates  a  patholoj?ic 
condition.  Either  the  pupil  is  continuously  and  per- 
manently abnormal  in  regard  to  its  contraction  or  dila- 
tation (e.  g.  often  and  very  early  in  cerebral  syphilis), 
or  else  the  condition  changes  so  that  one  pupil  sud- 
denly becomes  much  dilated  or  contracted  (Springende 
Pupillen,  an  early  symptom  of  progressive  paralysis). 

Normally,  the  pupils  contract  equally  when  light  is 
thrown  into  them,  and  it  is  a  matter  of  indifference 
into  which  eye  the  light  is  cast,  for  the  other  eye  reacts 
similarly  (consensual  reaction). 

Above  all  else,  we  investigate  the  pupillary  reaction 
from  direct  light  and  the  convergence  reaction  of  both 
eyes.  If  the  pupils  remain  inactive  in  these  two  tests, 
there  is  an  absolute  pupillary  immobility;  if  they  do 
not  react  to  light  but  respond  to  the  convergence  test, 
it  is  termed  a  reflex  immobility. 

The  case  represented  in  Fig.  73  is  that  of  a  man, 
aet.  45,  who,  when  30  years  of  age,  was  infected  with 
syphilis. 

Anisocoria  is  present,  the  left  pupil  is  strikingly 
contracted  (spinal  miosis)  and,  furthermore,  it  is 
clearly  seen  that  the  pupils  are  not  circular,  a  condi- 
tion very  indicative  of  tabes  and  paralysis  (entrun- 
dete  Pupillen),  not  to  be  confused,  however,  with  the 

124 


Tab.  XLIX, 


Fig.  73. 
Anisocorid.     Reaction  of  pupils  in  Tabes. 


jbin.TU  Cotnpany,  New  York. 


dentated  pupil  from  synechiae,  adhesions  due  to  in- 
flammation. 

There  is  also  a  reflex  immobility  of  the  pupil,  i.  e. 
both  pupils  remain  unaffected  by  light  but  react  to 
convergence. 

The  accomodation  also  is  paretic,  a  fact  which,  pri- 
marily, led  the  patient  to  the  oculist. 

Vision  and  the  field  of  vision  are  normal  and  hence 
there  is  no  atrophia  nervi  optici  tabetica  incipiens 
present. 

The  patient,  with  the  exception  of  a  little  rheuma- 
tism, considers  himself  perfectly  well.  Lancinating 
pains,  however,  with  anesthetic  areas  in  the  lower 
limbs,  absence  of  knee-jerk,  and  the  presence  of  Eom- 
berg's  sign  confirm  the  diagnosis  of  tabes  dorsalis 
already  arrived  at  by  the  oculist. 


125 


Cataract  (Crauer  Star). 

Plate  L.,  Fig.  74 ;  Plate  LI.,  Fig.  75 ;  Plate  LII.,  Figs. 

76-79. 

Morbid  alteration  of  the  lenticular  tissue  is  usually 
due  to  disturbance  of  nutrition,  which  exliibits  itself 
as  opacity  of  the  lens :  cataract  {Kara  and  pijyw/^t,  to 
fall  down,  descend). 

Cataracts  vary  much  in  regard  to  species  and  com- 
position, and  may,  therefore,  be  classified  from  various 
points  of  view,  viz. : 

I.  Progressive  {e.  g.  cataracta  senilis,  which  contin- 
uously augments  with  age,  although  with  various  de- 
grees of  rapidity)  and  stationary  {e.  g.  cataracta  zonu- 
laris,  which  remains  unchanged  for  years  or  even  a 
lifetime). 

II.  According  to  maturity.  A  cataract  is  said  to  bo 
mature  when  the  lens  is  completely  opaque,  even  to  the 
capsule  and  into  the  periphery.  In  accordance  with 
this,  we  differentiate  as  progressive  forms :  Cataracta 
incipiens,  nondum,  fere  matura,  hypermatura,  the  last 
indicating  a  retrogressive  process  following  maturity, 
and  characterized  bj'  shriveling,  proliferation  of  cap- 
sular endothelium,  calcification,  etc. 

III.  Simplex  or  complicata.  A  better  nomenclature 
would  be  "primary"  or  "secondary,"  but  the  latter  is 
already  used  to  designate  another  form  of  cataract, 
i.  e.  the  more  or  less  thick  membrane  left  after  extrac- 
tion of  the  lens,  or  which  is  formed  anew  from  the 
residual  capsule,  endothelium,  and  fragments  of  the 
lens  not  extracted.    Cataracta  simplex  is  present  when 

126 


ff,  Atlas. 


Tab.  L. 


Fig.  74. 
Arcus  senilis  corneae.     Cataracta  senilis  matura. 


'onipniiy.  New  York 


eff.  Atliis. 


Tail.  LI. 


Fig.  75. 
Cataracta  morgagniana. 


ceff,  Atlas. 


Tab.  Lll. 


Fig.  76. 
Cataracta  zonularis 


Fig.  77. 
Cataracta  zonularis  willi  Cataracta  stcllata 


Fig    7<s. 
Cataracta  senilis  iiicipiens. 


Fig.  79. 
Cataracta  capsularis. 


an  Comnanv.    New  Yi)r]<. 


the  lens  alone  is  affected  but  is  yet  able  to  perceive 
light,  the  eye  being  otherwise  sound.  We  speak  of 
cataracta  complicata  when,  to  an  internal  blindness, 
there  is  added  an  opacity  of  the  lens.  Both  forms 
may,  externally,  look  alike,  but  clinically  they  are  eas 
ily  differentiated  by  the  tests  for  light  and  projection. 

IV.  According  to  the  age  of  the  patient :  Cataracts^ 
congenita,  mollis  or  juvenalis,  dura  or  senilis.  The 
congenital  cataract  or  that  found  in  youth  is  not  al 
ways  amenable  to  strict  classification,  and  offers 
scarcely  any  pathologic  or  anatomic  deviations.  We 
have  no  precise  knowledge  in  many  cataract  forms 
whether  they  were  congenital  or  first  developed  in  the 
early  years  of  life,  and  we  are  often  dependent  upon 
anamnesis  only.  Contrarily,  there  is  great  difference 
between  the  soft  and  hard  forms.  In  youth,  the  lens 
is  of  a  soft  and  uniform  consistency,  and  when  re- 
moved with  its  capsule  endeavors  to  assume  a  globu- 
lar form  In  the  course  of  years  the  central  portions 
gradually  become  denser  and  harder,  and  usually 
when  the  patient  attains  the  age  of  30  there  is  present 
a  firm,  unyielding,  unchangeable  nucleus  or  kernel 
which  does  not  react  to  contact  with  the  aqueous  hu- 
mor. After  that  age,  therefore,  we  consider  the  cat- 
aracta dura  as  important  from  the  viewpoint  of  oper- 
ative ophthalmology. 

V.  According  to  the  form.  Cataracta  zonularis  is 
the  most  frequent  and  characteristic  form  in  youth. 
In  this  zonular  or  lamellar  form,  a  cloudy  or  opaque 
stratum  develops  between  the  center,  which  remains 
transparent,  and  the  cortex  {vide  Plate  LIL,  Fig.  77). 
Sometimes  from  this,  small,  densely  opaque  projec- 
tions push  peripherally  into  the  transparent  zone 
(Plate  LII.,  Fig.  76).  From  cataracta  zonularis,  a 
number  of  other  forms  may  develop,  for  example: 

127 


If  the  opacity  extends  through  the  center,  we  have 
a  cataracta  centralis  (not  miclearis,  since  no  nucleus 
is  present  before  the  age  of  30). 

If  the  periphery  also  is  Ukewise  involved,  we  have  a 
cataracta  totalis.  These  three  forms  may  pass  into 
or  develop  from  one  another,  and  the  cataracta  totalis 
may  undergo  the  following  modifications: 

Its  contents  may  reach  such  a  degree  of  softening 
that  they  become  thin  and  milky,  cataracta  lactea,  or 
clear  so  as  to  resemble  a  cyst,  cataracta  cystica.  Later, 
not  only  the  subcapsular  stratum  but  the  contents  may 
calcify,  become  hard  and  chalky-white,  cataracta  cal- 
carea.  If  the  watery  contents  be  early  resorbed  so 
that  there  is  left  only  a  thin  wall,  composed  of  capsule 
and  some  epithelial  proliferations,  we  have  a  cataracta 
membranacea,  or  if  the  epithelial  cells  beneath  the  cap- 
sule calcify,  thus  forming  a  thin,  stiff,  chalky-white 
stratum,  we  have  cataracta  papyracea.  If,  however, 
the  capsule  is  not  reduced  to  a  papyracous  layer,  but 
remains  distended  after  resorption  of  its  contents,  it 
is  called  cataracta  aridosilicata. 

Cataracta  fusiformis  (spindle-shaped  cataract)  or 
axialis  is  a  congenital  and  rare  form,  having  a  spindle- 
shaped  opacity  in  the  axis  of  the  lens,  joining  the  an- 
terior and  posterior  poles. 

Cataracta  capsularis.  There  is  no  actual  opacity  of 
the  capsule.  The  opacity  is  in  the  anterior  surface  of 
the  lens  beneath  the  capsule,  and,  after  calcification,  is 
white  in  color  (vide  Plate  LII.,  Fig.  79).  If  such  an 
opacity  is  located  like  a  point  or  dot  just  at  the  ante- 
rior or  posterior  pole,  we  have,  respectively,  a  catarac- 
ta polaris  ant.  or  post.  The  former  may  project  like  a 
pyramid  or  cone  into  the  anterior  chamber,  cataracta 
pyramidalis. 

In  cataracta  stellata  the  cement  substance  of  the 
lenticular  fibers  is  clouded  so  that  the  star  becomes 

128 


visible  on  the  anterior  or  posterior  surface.  In  Fig. 
77  (Plate  LII.)  this  star  figure  is  seen  at  the  anterior 
pole  of  a  cataracta  zonularis. 

Cataracts  appearing  in  middle  life  often  consist  of 
gray  points,  cataracta  punctata,  or  stripes,  cataracta 
striata. 

VI.  According  to  origin,  we  have:  Cataracta  se- 
nilis (cortiealis  or  nuclearis),  beginning,  usually,  with 
spoke-like  opacities  lying  between  the  nucleus  and  cor- 
tex, and  which,  wedge-like,  push  from  periphery  to 
center,  thus  resembling  spokes  in  a  wheel  {vide  Plate 
LII.,  Fig.  78).  This  grayish  clouding  of  the  cortex, 
which  later  becomes  more  homogeneous  (Plate  L.,  Fig. 
74),  is  to  be  distinguished  from  an  opacity  of  the  nu- 
cleus, which  is  more  of  a  brownish-red  in  color  (Fig. 
78-79). 

Cataracta  nigra  is  a  peculiar  form  of  senile  cataract, 
where  the  pupils  appear  black  although  the  lens  is 
opaque.    It  is  due  to  extreme  sclerosis  of  the  nucleus. 

Cataracta  morgagniana  is  a  senile  form  where  the 
cortex  has  liquefied  so  that  the  brown  nucleus  floats 
about  in  it.  When  the  patient  stands,  the  nucleus  sinks 
(vide  Plate  LI.,  Fig.  75). 

Other  forms  are  cataracta  diabetica,  nephritica, 
traumatica.  Forms  due  to  some  general  disease  are 
called  constitutional  cataracts,  the  best  example  of 
which  is  the  cataracta  diabetica,  also  the  nephritica, 
and,  according  to  many  authors,  the  senilis.  Poison- 
ings may  likewise  cause  cataract  formation,  e.  g.  from 
ergotin.  The  ergotin  cataract  is  similar  to  the  experi- 
mentally developed  naphthalin,  sugar,  and  salt  cat- 
aracts. 

If,  moreover,  a  cataract  has  become  adherent  to  the 
iris,  an  iritis  with  the  formation  of  posterior  synechia 
must  have  preceded  it,  and  it  is  called  cataracta  ac- 
creta. 

129 


Dermoids. 

Plate  LIU.,  Figs.  80-81. 

Dermoids  are  congenital,  cystoid  tumors,  whose 
walls  are  dermal  in  structure,  although  the  tumors 
are  found  where,  normally,  dermal  elements  are  ah 
sent. 

In  the  eye  they  are  found  especially  in  two  places: 
(1)  At  the  corneo-scleral  junction,  and  (2)  under  the 
skin  on  the  bony  margin  of  the  orbit.  In  rare  cases 
they  extend  from  these  sites  farther  into  the  orbit, 
thus  interfering  more  or  less  with  the  eyeball. 

( 1 )  The  dermoid  tumors  of  the  corneo-scleral  junc- 
tion are  dense,  of  a  porcelain-white  or  dull-rose  color, 
and  most  often  found  at  the  external  margin  of  the 
cornea  between  the  muscle-insertions.  They  are  but 
little  elevated  above  the  surface  of  the  bulbus,  but  are 
deeply  and  immovably  imbedded,  partly  in  the  corneal 
substance,  partly  in  that  of  conjunctiva  and  sclera. 
They  are  always  congenital,  and  so  characteristic  as 
to  be  difficultly  confused  with  other  tumors. 

Microscopically,  the  structure' is  like  that  of  a  piece 
of  skin :  an  epiderm  of  several  strata,  and  below  it  a 
connective  tissue  stroma  with  sebaceous  glands  and 
hair  follicles.  The  superficies  is  often  covered  with 
a  fine  down.  Von  Duyse  attributes  their  development 
to  adhesions  betwixt  amnion  and  the  surface  of  the 
eyeball,  whilst  Remak  considers  them  fetal  invagina- 
tions of  ectoderm. 

Dermoids  in  children  are  usually  small,  on  an  aver 
age  about  the  size  of  a  lentil,  but  in  later  life  they  may 

130 


Tab. 


Fig.  80. 
Derinoidcyst  of  the  Cornea-scleral  margin. 


Fig.  81. 
Dermoidcyst  of  the  orbital  rim. 


begin  to  grow.  Because  of  this  and  the  ugly  disfigure- 
ment of  the  eye,  their  early  removal  is  to  he  commend- 
ed. With  most  of  these  dermoids,  the  bulbus,  as  such, 
remains  intact  congenitally  and  is  well  formed.  But 
a  second,  though  rare,  group  show,  in  varying  degree, 
a  congenital  interference  of  the  dermoid  with  the  de- 
velopment of  the  eyeball. 

Schmidt-Rimpler  described  such  a  dermoid,  the  lens 
having  been  dislocated.  On  the  cornea  of  a  calf's  eye 
was  a  piece  of  skin  with  hair,  which  began  on  the  inner 
margin  of  the  cornea,  covering  the  greater  part  there- 
of. The  iris  had  adhered  to  the  corneal  rudiment,  and 
there  was  no  anterior  chamber.  The  lens  projected 
through  the  pupil  into  the  dermoid,  thus  being  trun- 
cated. 

A  still  more  interesting  case  is  from  von  Griife's 
clinic.  The  timior  was  congenital,  and  during  the 
eight  months  of  the  child's  life  had  nearly  doubled  in 
size.  It  was  divided  into  two  large  portions.  The  en- 
tire cornea,  excepting  a  narrow  border,  was  covered 
with  an  ordinary  dermoid  which  was  connected  by  a 
short  stem  with  a  dermoid  of  cherry-size  projecting 
out  of  the  palpebral  fissure.  The  tumor  was  covered 
with  cutis  on  which  were  a  few  hairs.  Apparently, 
there  was  no  lens  in  the  globe.  Microscopically,  the 
dermoid  showed  cutis  with  hair,  sebaceous  glands,  iso- 
lated papillff,  hair  follicles.  The  cornea  was  lacking, 
its  place  being  taken  up  by  connective  tissue,  to  which 
the  iris,  recognizable  by  a  thick  stratum  of  pigment, 
had  grown. 

Bernheimer  describes  a  child,  aet.  6  months,  with  two 
cherryrsized  tumors  in  the  right  eye,  which  almost 
touched  one  another,  keeping  the  lids  apart.  Later, 
they  increased  in  size,  entirely  covering  the  cornea. 
Anatomically,  there  was  a  total  corneal  staphyloma 
with  iridic  proliferation. 

131 


In  a  ease  of  Manfredi  the  well-formed  orbit  con- 
tained, not  an  eye,  but  a  sphere  the  size  of  a  pea.  The 
abnormality  increased  somewhat  with  the  growth  of 
the  child.  The  eyeball  stump  was  covered  anteriorly 
with  a  white,  hairy  skin.  An  excised  portion  showed 
the  histologic  structure  of  a  dermoid. 

Wagenmann  examined  a  tumor  from  the  orbit  of 
a  new-born  child.  Posteriorly  it  was  joined  to  the  or- 
bit by  a  stem,  the  size  of  a  quill.  This  stem  was  cut 
through  and  the  orbit  of  the  otherwise  healthy  and 
well-formed  infant  was  precisely  like  that  resulting 
from  enucleation.  The  cavity  was  covered  with  a 
mucous  membrane.  On  section,  the  tumor  was  found 
to  contain  a  piece  of  bone  and  a  rudimentary  eyeball. 
A  cross-section  showed  the  tumor  covered  by  a  cutis 
about  1  mm.  thick,  with  fine,  down-like  hairs. 

II.  Dermoid  cysts  of  the  skin  of  the  lids  or  of  their 
subcutaneous  tissues  are  almost  always  located  exte- 
riorly on  the  orbital  edge.  They  are  not  very  infre- 
quent, usually  as  large  as  a  pea  or  plum-pit,  though 
they  may  later  increase  in  size.  Commonly  they  are 
firmly  adherent  to  the  periosteum  of  the  orbital  mar- 
gin. These,  too,  are  congenital  cysts  with  firm  walls, 
and  the  pap-like  contents  are  composed  of  desquamat- 
ed, cornified  cells  and  detritus,  sometimes  fat  and 
hairs. 

The  tumors  are  to  be  considered  as  due  to  a  stratimi 
of  germinal  epithelium  deposited  on  the  areas  affected. 

It  is  well  known  also,  that  such  dermoid  cysts  may 
be  found  deeper  in  the  orbit. 


132 


Fig.  82.     E.xophthalmiis  caused  l)y  Tumor  retrobulbaris. 


'4 


Fig.  S3. 
Tiie  Tumor  after  Exstirpation. 


Fig.  84.      Microscopic  section  of  the  tumor. 


an  Company,  New  York. 


Exophthalmus. 

Plate  LIV.,  Pigs.  82,  83,  84. 

By  exophthalmus  we  understand  a  remarkable  con- 
dition where  the  eyeball  is,  more  or  less,  thrust  for- 
ward out  of  its  orbit.  Exophthalmus  is  not  to  be  con- 
fused with  a  condition  where  the  eyeball  is  enlarged, 
and  hence  projects  somewhat  from  the  orbit,  but  still 
remains  in  its  place. 

Fig.  82  is  the  case  of  a  woman,  set.  60,  in  whom  the 
right  bulbus  in  course  of  2  years  gradually,  painlessly 
and  without  inflammatory  symptoms  advanced  out- 
ward, forward  and  downwards. 

In  this  case,  the  first  species  of  exophthalmus,  the 
inflammatory,  could  be  excluded,  for  it  develops  sud- 
denly, as  a  rule,  or  rapidly  from  exudates,  often  from 
collection  of  pus,  or  follows  inflammation  (periostitis, 
ostitis)  of  structures  posterior  to  the  eyeball.  Fre- 
quently it  follows  the  outbreak  of  pus  from  some  cav- 
ity adjacent  to  the  orbit.  The  lids  become  very  edema- 
tous, swollen  and  red,  chemosis  sets  in,  etc.  In  our 
case  there  were  only  a  few  small  blood-vessels  of  the 
conjunctiva  bulbi  dilated. 

Nor  were  we  dealing  with  a  pulsating  exophthalmus, 
iphich  is  usually  caused  by  an  aneurysma  arterio-veno- 
sum  due  to  a  rupture  of  the  carotid  in  the  sinus  cav- 
ernosum.  In  such  case,  the  palpating  hand  distinctly 
feels  a  pulsation  of  the  bulbus  or  the  pulsation  may  be 
seen  with  the  naked  eye. 

A  non-inflammatory,  simple  exophthalmus  is  found 

133 


(a)  in  morbus  Basedowii,  (b)  with  retrobulbar  tumors. 
The  first  possibility  was  easily  excluded  in  this  case. 

We  had  to  do,  then,  with  a  retrobulbar  tumor,  and, 
because  of  its  very  slow  growth,  with  a  relatively  be- 
nign one. 

Two  circumstances  permitted  the  elimination  of  a 
tumor  of  the  optic  nerve,  which  is  not  rare.  In  the 
first  place  such  a  tumor  commonly  drives  the  bulbus 
directly  forwards,  and  secondly,  vision  was  still  fairly 
good,  whilst  in  optic  nerve  tumors  it  is  soon  lost  from 
compression  of  the  optic  fibers.  (Moreover,  the  optic 
nerve  lies  behind  the  bulb  in  the  form  of  the  letter  S, 
and  hence,  when  pulled  upon  by  an  exophthalmus,  is 
able  to  stretch  or  yield  without  danger.) 

Nor  were  we  dealing  with  one  of  the  relatively  more 
frequent  tumors  of  the  lacrimal  gland,  which  would 
have  pushed  the  eyeball  downward  and  toward  the 
nose. 

The  eyeball  was  quite  movable ;  hence,  the  tumor  was 
not  adherent,  and  probably  did  not  rise  much  above 
the  adjacent  tissue  (e.  g.  the  muscles).  The  nose  and 
all  cavities  near  the  orbit  were  free,  so  that  the  tumor 
probably  had  origin  in  the  orbit,  and  had  remained 
there.  Pressing  inward  with  the  finger  on  the  upper 
lid  between  bone  and  eyeball,  two  hard  nodes  were  en- 
countered. Hence,  cysts,  entozoa  (echinococcus,  cysti- 
cercus)  and  lipomata,  which  are  softer,  were  likewise 
eliminable. 

We  thus  arrived  at  the  exact  diagnosis  of  a  hard, 
probably  capsulated,  fibroma,  whose  site  and  size  were 
just  as  accurately  demonstrable. 

Tberapy.  Removal  of  the  tumor  was  indicated 
by  the  slow  but  steady  growth.  As  soon  as  an  exoph- 
thalmus attains  a  size  which  prevents  closure  of  the 
lids,  the  situation  becomes  very  tormenting. 

134 


As  operative  measures  were  discussed:  The  clear- 
ing out  of  the  whole  orbit,  thus  sacrificing-  the  eyeball ; 
the  anterior  removal  of  the  growth,  saving  the  eyeball ; 
removal  by  the  temporal  route  (Kronlein's  method), 
saving  the  eyeball. 

Since  the  tumor  was  indubitably  benign  and  encap- 
sulated, the  first  operation  was  not  indicated ;  further, 
as  its  site  was  on  the  nasal  side,  the  Kronlein  proced- 
ure was  abandoned. 

After  finding  the  tendon  of  the  muse,  rectus  int.  bulbi, 
which  was  caught  up  and  cut,  the  bulb  was  drawn 
down  and  outwards  with  dull  tenacula,  and  a  hard  tu- 
mor, the  size  of  a  small  hen's  egg,  and  attached  to  the 
deeper  tissues  only  by  a  thin  stem,  was  shelled  out 
(Fig.  83),  Microscopically,  it  proved  to  be  a  dense 
connective  tissue  growth,  rather  rich  in  cells  (Fig. 
84). 

The  eyeball  was  replaced  and  the  muscle  tendon  sut- 
ured. There  has  been  no  return  of  the  tumor,  and  the 
eyeball  is  in  good  condition. 


135 


Index 


Anisocoria  . . 
Anthrax  . . . 
A  reus  senilis 
Atheroma    . . 


Blepharitis  marginalis 
Buphthalmus   


Carcinoma  epibulbare   

Carcinoma  epitheliale 

Cataracta  capsularis 

Cataracta  morgagniana  

Cataracta  senilis   

Cataracta  stellata 

Cataracta  zonularis 

Chalazion    

Coloboma  iridis  artificiale 

Coloboma  iridis  congenitum. . . 

Condj'lomata  iridis 

Conjunctivitis  catarrhalis  . . . . 
Conjunctivitis  diphtheritica   . . 
Conjunctivitis  exanthematica 
Conjunctivitis  foUicularis   . . . . 
Conj.  gonorrhoica  adultormn   . 
Conj.  gonorrhoica  metastatiea 
Conj.  gonorrhoica  neonatorum 
Conj.  gonorrhoica :  Sequelae   . . 

Conjunctiva  normal  

Conjunctivitis  phlyctenulosa   .  . 

Conj.  simplex  chronica 

Conj.  trachomatosa    


PAGE 

124 

9,11 

105 

21 

32 

108 

86 
51 

128 
129 
127 
128 
127 

28 

76 
119 
116 

59 

79 
7 

61 

73 

74 

71 

75 

58 

81 

33 

63 


PLATE 

XLIX. 
IV.  V. 

L. 

XI. 

XIII. 
XL. 

XXXI. 

XVI.  XVII. 

LII. 

LI. 

L.  LII. 

LII. 

LII. 

XIII. 

XLVIII.  XXIV. 

XLVIII. 

XLVI. 

XIX. 

XXVII. 

IIL 

XX. 

XXVI. 

XXIV. 
XXIV. 

XIX. 
XXIX. 

XIV. 
XX.  XXI. 


FIG. 

73 
4,5 
74 
13 

I   3,16,18, 
i      41, 42 

58 

45 
20,21 

79 

75 
74,78 

77 
76,77 
16,17 
35,72 

71 

66 

25 

40 

3 

26 

38 

34 

35,  36,  87 

24 

42 

18 

27,  28,  29 


137 


Conj.  vernalis 
Cornea  globasa 


Corneal  opacities 


Dacryocystitis  acuta    . . 
Dacryocystitis  chronica 

Dermoid  cyst  

Dermoid  tumor   


Ectasia  eorneae   . 

Ectasia  scleras    . . 

Ectropium    

Entropium    

Episcleritis 

Erysipelas  faciei 
Exophthalmus    . . 


Gangrene  of  Lids 

Gerontoxon,   (Arcus  senilis) 

Glaucoma    

Gumma  iridis 


Haemorrhagia  subconjunctivalis 

Haemorrhagia  subdermalis 

Herpes  facialis 

Herpes  zoster  gangraenosus    . . . 
Herpes  zoster  ophthalmicus   . . . . 

Hordeolum    

Hutchinson 's  Teeth 

Hyperemia  marginalis 

Hypopyon-Keratitis    


Iritis 


Keratitis   

Keratitis  fasicularis   

Keratitis  interstitialis    . . . 
Keratitis  parenchymatosa 
Keratitis  phlyctaenulosa   . 

Keratitis  punctata    

Keratoconas   

Keratoglobus 


PAGE 


PLATE 


83 

XXX. 

43,44 

107 

XL. 

58 

93 

(        XXXIV.       ) 

jxxxvin.  L.  • 

35,  55,  74 

56 

XVIII. 

22 

54 

xvin. 

23 

130 

Lin. 

81 

130 

LIII. 

80 

107 

1   XXXIX.  XL.  ) 
j          XLI. 

56,  57,  58,  59 

112 

XLV. 

63 

47 

XV. 

19 

42 

XIV.  XXII. 

18,31 

112 

XLIV. 

62 

1 

I. 

1 

133 

LIV. 

82 

11 

V. 

5 

105 

L. 

74 

122 

XL  VIII. 

72 

116 

XLVII. 

67 

4 

II. 

2 

4 

II. 

2 

14 

VI. 

6 

14 

VII. 

8 

14 

vn. 

7 

24 

XII. 

15 

96 

XXXIV. 

49 

33 

XIV. 

18 

101 

XXXVII. 

53 

115 

XLVI.  XLVII. 

(  64,  65,  66, 

\  67,  68,  69 

92 

XXV.  XXXII. 

36,47 

92 

XXXII. 

47 

92 

XXXIII. 

48 

92 

XXXIII. 

48 

81 

XXIX.  XXXII. 

42,47 

111 

XLII. 

60 

107 

XXXIX. 

56 

107 

XXXIX. 

56 

FIG. 


138 


Lacrimal  Sac:  Congenital  Affections  of. 
Lepra    


Leucoma  cornese 


Lipoma  subconjunctivale 
Lupus  vulgaris 


Membrana  papillaris  inflammatoria 
Membrana  pupillaris  perseverans  . . 

Molluscum  contagiosum 

Morbilli  


Occlusio  pupillaj   . . . . 
Oedema  palpebrarum 


Pannus    

Pericorneal  Injection  . . 

Phlyctenula    

Phthisis  bulbi  incipiens 
Phthisis  bulbi  quadrata 

Pinguecula   

Primary  Infection 

Pterygiiun   

Pupillary  Difference    . . 

Pupillary  Fixity 

Pustula  maligna   


Rachitic  Teeth  . 
Rhagades  faciei 


Saddle  nose   

Selerectasiae    

Scleritis    

Seclusio  pupillae  

Skull  formation  in  hereditary  lues. 

Staphyloma  corneaj  partiale    

Staphyloma  eorneje  totale    

Synechiffi  posteriores 

Syphilide  (papular) 


Tabes 
Teeth 


PAGE 

55 
110 

104 

91 
49 

120 

120 

22 

7 

116 
1 

67 
115 

81 
72 
72 

77 

18 

77 

124 

124 

9 

96 
97 

97 
112 
112 
116 

97 
107 
107 
115 
116 

124 
96 


PLATE 

XLII. 

XXIV.  XXXVIII. 

XLIII. 

XXXII. 

XV. 

XLVII. 
XLVII. 

XI. 

III. 

XLVII. 
I. 

XXII. 

XLVI. 

XXIX. 

XXV. 

XXV. 

XXVI. 

IX. 
XXVI. 
XLIX. 
XLIX. 

IV. 

XXXIV. 
XXXV. 

XXXIII. 

XLV. 

XLIV. 

XLVII. 

XXXVI. 

XXXIX. 

XLI. 

XLVI.  XLVII. 

IX.  XLVI. 

XLIX. 
XXXIV. 


PIG. 

60,61 

35,55 

46 
19 

69 
70 
14 
3 

69 
1 

30 
64 
42 
36 
37 
39 
11 
39 
73 
73 
4,5 

50 
51 

48 
63 
62 
69 
52 
57 
59 
65,  67, 
64 


69 


73 

49,50 


189 


Trachoma   

Trachoma  (cicatrix)    

Trichiasis    

Tubercles  of  the  Iris 

Tumor  of  Corneo-scleral  Margin 
Tumor  retrobulbaris 

Ulcus  durum   

Ulcus  serpens   

Ulcus  serpens  progressivum .... 

Variola    vaccina 

Variola  vera    

Xanthelasma  

Xeroderma  pigmentosum 

Xerophthalmus  trachomatosus. . 


PAGE 

63 
68 
38 

116 
86 

134 

18 
101 
102 

16 
104 

20 

86,87 

69 


PLATE 

XXI.  XXII. 

XXIII. 

XXII. 

XLVII. 

LIII. 

LIV. 

IX. 
XXXVII. 
XXXVII. 

VIII. 
XXXVIII. 

X. 
XXXI. 
XXIII. 


FIG. 

27,  28,  29 
31,32 

18 
68 
45 

82 

11 
53 
54 

9,10 
55 

12 
45 
33 


140 


uaie 

uuc 

x^ 

y 

T               / 

■ 


iiniii»i'*i"' 


000  224  995  1 


WW17 
GT93a 

1909 

Greeff,  Richard 

Atlas  of  external  diseases  of 
the  yey... 


J 


WW17 
G793a 
1909 
Greeff,  Richard 

Atlas  of  external  diseases  of  the  eye 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


•mjini/r'? 


ii*r 


